[uplifting instrumental music]
>> Let me take a show of hands here.
How many of you have
walked with a loved one
through the end of life?
Oh okay, a lot of you.
I suspect if you have
not done that personally,
you will at some point with
your parents most likely.
Every once in a while we
have people who have walked
through this with a spouse or a sibling
and God forbid that you would ever have to
walk through this with a child.
I spoke on this at a
church about a year ago
and a woman approached me
afterwards and she said
we just walked this journey
with our three-year-old child.
And she wrote a book about
it and she gave me the book,
I started it one afternoon
and the rest of the day sort of went
before I put the book down.
Absolutely riveting.
But I mean, this is
where ethics and morality
really touches where we live.
Now those of you who have
walked with a loved one
through the end of life,
another show of hands here,
how many of you were involved in decisions
to remove some form of life support?
[mumbles]
Okay, all right.
Now the third and final
question on this short quiz,
of those of you that raised your hand,
how many of you felt
like you were prepared
for the decisions that you had to make?
Okay, one.
Why was that?
Because you had thought about this before?
>> Man: Yeah, I mean this was years ago.
[distant indistinct muttering]
>> Okay.
I suspect most people in our churches
who have had to do this
feel completely unprepared.
I spoke on this in my own
church over Memorial Day.
And about probably 80, 85% of the people
raised their hand to the first question
of having walked with a loved one.
Virtually no one raised their hand
when they said they felt well prepared.
And what I wanna do, the
goal for this session
is to give you the tools
to walk with people
through the end of life, okay?
And there's a whole lot to
this in terms of bioethics.
But there's also a
pastoral dimension to this
that's really important that
I think we need to attend to
because at the end of the day,
what will carry the
argument against euthanasia
and assisted suicide is the
way we in our communities
care for people at the end of life.
Because what drives the
movement toward euthanasia
and assisted suicide is the fear of dying
in isolation, in pain
and without resources.
What we found is that
when people have support
and when they have their pain controlled
and have some control over
the decisions that they make,
they wanna live.
That shouldn't be a huge surprise.
But generally, when there's
a positive alternative
to assisted suicide,
people will choose it.
The state of Oregon is a
really good example of this.
Oregon, it's been about
probably 10 years ago now,
became the second state
out of three to pass a law
legalizing assisted suicide.
What they've discovered over the time
the law has been in
place is how few people
have actually availed
themselves of the law.
And in fact, I think the
public health officials
have been pretty surprised at that.
And the reason for it is that
the way, for one, pain management
in the state of Oregon
is considerably ahead
of the rest of the country.
But there's also an ethos
where people are cared for
in their communities and
there's an alternative
that's perceived to assistance in suicide.
And again, if their pain is managed well,
then people generally wanna live
and don't take advantage of the law.
Montana just recently
legalized assisted suicide.
It'd be very interesting if
that works out the same way.
I think there's less hope for
major metropolitan
areas where people live,
basically separated from
their extended families,
and people are much more apt to die alone
and in isolation, right?
So on the bigger picture of that,
that's what's important on
this, that at the end of the day
we present a positive Christian vision
for what death and dying looks like
as opposed to just saying no to euthanasia
and assisted suicide,
which we should be doing,
but not without an alternative.
And some of the alternative...
[audience chuckling]
There we go.
Don't put that up on the web.
[audience laughing]
Some of the alternative
involves how we deal
with medical treatments
at the end of life, right?
Generally, I think when it
comes to treating people
at the end of life, what
people are most afraid of
is the sort of a run away
train of medical treatment
that can't be stopped and that most people
are very afraid of lingering
in really compromised health situations.
So anyway, that's where
we wanna head with this
and this is really, I'm so
delighted that my church
gave me the opportunity to talk about this
and I was inundated both in
between services and after
with people who were just
grateful that we've you know,
we've kind of come out from the closet
and talked about this a bit.
They're very grateful for that.
So sort of that's a secondary goal to this
is for you guys to have some of the tools
to be resource people in your churches
for your pastors and better yet,
for the healthcare professionals
who are in your churches.
I suspect that the
average physician, nurse,
social worker, hospital administrator,
I bet you they would
fall out of their chairs
if they heard some of this
addressed in your churches.
And I suspect that the
healthcare professionals
who are in our churches
consider the churches
and the pastoral staff
some of the last places
that they would look
for resources on this.
And I think that's too bad
because you guys are
the ones who live life
with the people in your churches.
You know them, you know their values.
You guys and the pastors in your church
are the best equipped to
walk through the end of life
with these folks.
I've been beaten on my seminary
students for this for years,
saying that they should be calling you,
not the hospital chaplains,
though those are good folks generally,
but they shouldn't be
taking a lot of this advice
from their physicians or
from hospital personnel
who don't know them, probably don't share
all the components of
their view of the world.
You're the ones that do that.
The hospital personnel certainly haven't
lived life with them.
No, you have, and you
guys need to be the ones
who are walking through this with them.
So I wanna give you some tools.
Hopefully we'll do more
than just give you enough
to make a dangerous.
[audience chuckling]
That would be nice if
we could pull that off.
Okay, now just to be clear about this,
we're talking about three
different things here, okay?
TLS, I'm gonna use the initials for this,
TLS stands for the
termination of life support,
also known as the withholding
or the withdrawing
of treatments at the end of life, okay?
Second, we'll refer to PAS,
or physician assisted suicide,
which is quite different
than removing a treatment.
And then third, we'll say a
little bit about euthanasia,
probably not quite as much
because there's no place
in the United States
where that's legal today.
But euthanasia is different
than assisted suicide
primarily because euthanasia occurs
when the patients are
too sick or debilitated
to actually utilize assistance.
They have to be directly,
I mean, it's the direct
intervention of the physician,
not for you personally of course,
as opposed to in assisted
suicide the physician
will prescribe, advise and supervise
the patient taking his or
her own life themselves.
Okay?
Usually, they will
prescribe a life-ending dose
of some sort of medication
that will stop their heart
then slow their breathing
to virtually nothing.
And they'll advise them
about how to do this.
And then they'll be sort
of right there on call
if things don't go quite as planned.
And then with euthanasia,
they'll just basically
put the drug into the IV line
and take care of it like that.
There are a variety of cases of euthanasia
being performed today around the world,
both without the patient's consent
and without their knowledge.
So we'll talk a little more
about that toward the end.
Now what set the background
for a lot of this discussion
was a landmark study which you can read
if you wanna wade through this
in the Journal of the
American Medical Association.
The study was done in the mid to late 90s
and it was 10,000 patients.
And in order to get into the study,
you had to have one of about a dozen or so
clear life-threatening illnesses.
So admission to the study, if
you qualified for the study,
that was bad news about your
condition and your prognosis.
This was a study you did
not want to qualify for.
What they tried to measure,
and there are some assumptions
that went into this
but we'll try to spell those out,
one, they tried to discern if
and when DNR, do not
resuscitate, orders were written.
Anybody familiar what that is?
That's if you have a heart attack,
nobody's gonna perform CPR on you, okay?
Generally, what they concluded was that
if you didn't have a DNR order
or if it was written
in real close proximity
to the time you died,
chances are you were going to receive CPR
when, for one, the chances of it
doing you any good were small,
but also the chances of
it being harmful to you
were really significant.
I mean, CPR is designed for
basically people our age,
whose heart stops
suddenly and unexpectedly.
It was never designed for people
who are sick and debilitated
and have to have it chronically done.
In fact, if we ever performed
CPR on my father in law
on his dying days, they would
have broken most of his ribs,
probably punctured a lung
and probably 50/50 chance
of leaving him worse off
than had he actually died.
So anyway, that's the assumption
that if you didn't have a DNR order
or it was written just within a day or two
before your death, that you were getting
more aggressive treatment
than was warranted.
Second, they tried to assess
the way patients and physicians
communicated with each
other at the end of life.
And they just used the preference for CPR
as one indication of how
well the communication was.
That is, if the patient and physician
were in agreement about what the patient's
CPR preference was, what that suggested
was that they'd actually sat
down and talked about it.
If they hadn't, then that was
evidence of let's just say,
very poor communication
at the end of life.
If the physician doesn't know that,
then chances are they haven't talked about
hardly anything of substance
at the end of life.
Third were the number
of days spent in the ICU
or on mechanical ventilation.
Again, these are terminal illnesses
that people are dealing with.
They are not gonna get better.
They're gonna just go
progressively downhill.
The assumption here is
that what's appropriate
for most of these patients is a far less
aggressive level of
treatment than you would get
in an ICU or with full
mechanical ventilation.
In basketball terms, we would
say that's a full court press
for some people when it's
clearly not warranted.
Now there are some exceptions to this,
there are some times where
even at the end of life,
surgery would be appropriate
for comfort purposes.
For example, somebody with stomach cancer
at the end who's got
an intestinal blockage,
a surgery to remove that block
is really important for them
to stay comfortable.
And so not every instance
that you'd be in the ICU
would be inappropriate.
But as a general rule,
for patients who are terminally ill
and have just a few months to live,
the ICU is not the place that
they wanna spend their time.
Fourth, and this was probably
the most important one,
the frequency and severity
of pain that was experienced
by the patient.
Now it's a little bit
hard to quantify this,
but what they did was they did
it on a scale of one to 10,
you know, one being pain free,
10 being the worst pain imaginable,
and if you see some
hospitals they actually have
a series of faces to describe
the increasing levels of pain.
Okay?
And in hospital resource use,
that was sort of a moot point
at the time, it's far
less of a moot point today
because statistically, just
as a general statistic,
you will spend roughly half
of all of your health care expenses
in the last 12 months of your life
when arguably, now not for everybody,
but in many cases, the
last 12 months of your life
is the time when the treatment will do you
the least amount of good.
And that's not true for
everybody but in a lot of cases,
that is true.
Now what they found,
they had an educational
intervention with the physicians
which didn't really do much
so the findings were the same
before and after the education.
Almost half the DNR orders were written
within two days of the patient's death,
which is way too late in the process.
And patients were having
CPR performed routinely
when it clearly wasn't indicated.
Roughly half the physicians did not know
of patient's CPR preferences,
which reflects an abysmal
level of communication
at the end of life.
Now this I think has changed a little bit,
but the conditions for which this needs
to be done have deteriorated.
So I think physicians, they
are more sensitive to this
at the end of life.
But physicians today are busier
than they have ever been before.
And most physicians just don't have time
for extended conversations at the bedside
about the end of life.
And increasingly, the
physician you see in the office
is not the same one that you
will see in the hospital.
Meaning increasingly,
healthcare organizations
are going to specialists
who only see patients in the hospitals
and they don't have an office practice.
And so it may be that the
physician who's followed you
in the office will never
see you in the hospital,
which in my view is not you know,
in terms of the care of
patients is probably not
a great development and
it's where efficiency
conflicts with good care for patients.
This is where it starts to
get a little bit dicier.
Over 1/3 of these
irreversibly dying patients
spent at least 10 days of
their last hospital stay
in the ICU.
And what that indicates is a
level of aggressive treatment
that is way over the top
for basically patients who
belong in hospice care.
They're in the ICU, okay?
And then the one that really
got people's attention
was that 50% of patients or families,
if the patient had died,
reported being in moderate to severe pain
in the last few days of their life.
I would suggest that's
unconscionable for that to happen.
Now that I think has
gotten a lot better today.
Hospice care has become more widespread.
If you've had a loved one in hospice,
I suspect you've come away from that
looking at hospice personnel
as, if not angelic,
pretty close to it.
I mean, the hospice people
who took care of my dad,
they're my new heroes.
But to have people
suffering like that in pain,
that's why people want
assisted suicide on the books
because of that.
And I think if we treat
people's pain adequately
for the most part, they
won't be interested
in assisted suicide.
Now a follow up to this was
done about 10 years later.
In fact, the conclusion,
this is a serious understatement,
one commentator put it a
little bit more bluntly
when he said, if you are dying
and in a hospital, get out.
[audience chuckling]
And if you're not in a
hospital, don't go there.
Now I think it's improved significantly,
but the vast majority of people
die in a hospital setting
essentially surrounded by strangers
with tubes, treatments and technologies
that they probably don't want
but just haven't bothered to say so, okay?
Here's the fourth question on your quiz,
how many of you have an advance
directive or a living will?
Okay, one, two, three, four.
Good for you guys, shame
on the rest of you.
[audience chuckling]
No, I'm kidding sort of.
Jim, it's unusual that somebody
your age would have one,
but you've been down this road so you know
the drill on this.
For the rest of this,
if you were to come down
with a serious illness and
you were to lose the capacity
to make decisions for yourself,
who in your life would know
what your preferences are
at the end of life?
[indistinct chattering]
You hope.
[audience chuckling]
How many of you, if you're married,
how many of you had this
conversation with your spouse?
Okay, good, good, good, that's terrific.
Now there may be a good reason to go ahead
and write it down too
because I don't know,
your spouse may be different than mine,
I'm not totally persuaded
that my wife has the stomach
to do what I want done at the end of life.
I'm not sure about that.
I could see her getting a
little weak in the knees
and you know, keeping me
going and going indefinitely
on treatments and technologies
that I don't want.
I used to think that all you
need to do is tell somebody
and talk to them about it
until Terri Schiavo's case came along.
>> Woman: Yeah, that's when I got mine.
>> And you're wise to do that.
If she had written her wishes down,
I suspect none of this would
have gone to court at all
and we'll talk about
her case in a little bit
because that's one of the
screwiest cases of all time.
Question?
>> Yeah, that's really important
because of the reaction
that the medical officials have
by any of the family
members against the DNR.
It's still very powerful.
>> It is, it is.
No charge for this, but it is illegal
for somebody, for a
physician or a family member
to override a validly
written advance directive.
That's illegal, okay?
And the person you designate
to make decisions for you,
let's put it this way,
that is not an interpretive
function, right?
They don't get to
interpret your living will.
They don't get to look
at that and say well,
that's not really what she meant,
or I think I got a better idea.
So I'd say it's especially
important to write it down
if the person who you know will
be making decisions for you,
you may not be completely
sure when push comes to shove
that they'll do what you want.
Now there are limits on
what you can want of course,
and I'm glad my wife
would not have the stomach
to assist me in committing suicide,
you know, or authorizing
euthanasia for me.
But I am far more afraid
of lingering on and on indefinitely
and having somebody delay my homecoming
than I am of having the
plug pulled prematurely.
Now if I had my way, it's
probably illegal to require this
but if I had my way, you
couldn't pass this course
without completing an advance directive.
But I think the law would suggest
I don't have the authority to do that.
But it's a really good idea
and the form that the
state of California has
is actually a pretty good one.
It's not perfect but it's a good start.
And I would definitely talk
about this with your physician.
And once it's filled, those
you who haven't filled out,
do you know where it is?
Okay, does your physician
know where it is?
[audience chuckling]
Probably not good enough.
>> I can't control that.
>> No, I know.
But I would make sure that your physician
has a copy of it in your
chart because if you get
to the hospital and nobody knows
where that fool thing is,
you might as well not even have it.
So anyway, end the sermonette.
Now the second, this is
really important I think
as we walk with people
through the end of life,
this was basically a consortium
of Catholic hospitals,
basically said we read
a lot, we hear about
what people need and
want at the end of life
but we've never really
asked people ourselves
to tell us what they need
and want at the end of life.
And so the Supportive
Care of the Dying project
set out to do that.
They interviewed hundreds
of terminally ill, dying patients,
their families, their caregivers
and particularly the
people who survived them
after their deaths and
basically asked them
what do you need and
want at the end of life
from the healthcare system?
Some really interesting
things that they said.
For one, they said they
want to know the truth
and they want it communicated
regularly and in a timely way.
They want to know what their diagnosis is,
what their prognosis is
and where we're going with these
tubes, treatments and technologies.
This is a huge ethical
issue with some patients
from some parts of the world
who basically take on the burden
of decision making themselves
and take it off the patient.
In the United States, that's illegal to do
unless the patient himself or herself says
I want so and so to make decisions for me.
We had a case I consulted
on some time ago where,
this was a woman in her
60s with Hodgkin's disease
and her son, she didn't speak
any English, she's Hispanic,
and her son was serving as the translator
but he wasn't letting
information go back and forth
about her condition.
So all she knew was that she was sick
and that she was gonna have a treatment
that was gonna make
her sick to her stomach
and cause her hair to fall
out and that's all she knew.
And so we actually ended up getting
another translator in there
with the son in the room
and asked her do you wanna know
what's your condition, your prognosis?
And in her own kind of demure way,
she said of course I want to know.
At which point the son,
we had remove the son
and get another translator
in there full time.
So it's very clear people
wanna know the truth, okay?
Second, if you've ever cared for someone
who is at the end of life,
you'll resonate deeply with this.
So dying patients and their families
wanna be regarded as a single unit.
What they mean by that is that
whatever affects the patient
also affects the people who care for them.
That's not the way we treat it.
We treat the people who care for them
as virtually invisible.
And we assume that
they're just sort of like
energizer bunnies that can
continue to go on and on and on.
But if you ever cared for a dying person,
you know that's not true
and that the decisions about the patient
have a dramatic impact on
the people who care for them.
Third and fourth are
really important things
that I think often go
without being accomplished
and that is dying patients
and their families both
expressed a huge need to
close the loop relationally
before they die.
And to give your loved ones an opportunity
to take care of any unfinished business
and say the things that
you've always wanted to say,
to say the things to your
loved one that you will say
at their memorial service,
I'm so grateful I got to tell my dad
everything I wanted to
tell him before he died.
I'm so thankful for that.
That would have been tragic had I not had
the opportunity to do that.
And granted, some people
they get run over by a bus
and you just don't have
the chance to do that.
But when we do, you have to
realize how important that is
to family members.
And you guys can help,
you can encourage them
to say those things before they die.
The best thing you can do,
and this is really what the
families were so clear about,
is they need a heads up
that this day is coming.
And it's not that hard to predict.
I mean, people with
terminal illnesses know
that they don't have forever
to take care of this business.
And frequently, what
happens is that families
are given so much hope and optimism
by the medical community
that when the physician
finally says you know,
we probably ought to stop
treatments and move to hospice,
the family, they're completely
unprepared for that.
And so they've been getting
hope, hope, hope, hope, hope,
upbeat, optimism, and then finally
now these treatments are futile.
And what happens, the families,
that's why they dig their heels in and say
what do you mean you're
gonna stop these treatments?
Not a chance!
But they also missed the
chance to close the loop
before they die.
That's so important.
And I think you guys can help
the families because granted,
some families are just
in denial about this
and you're not gonna break through that.
But others need to hear it
from somebody close to them,
from their pastors, from
somebody in their church
or in their small group.
I mean, I've had countless physicians say
where is this person's pastor?
Where is their community to
help us resolve this conflict?
Because the family is saying
keep going, keep going
and the doctors are
saying what on earth for?
And that's what you guys
can help them with that.
Be aware how important
that is to give a heads up.
And you can even couch it optimistically.
You can say look, you know,
the doctors are saying
this will probably go well
but you ought to be
prepared given you know,
given dad's age and his general condition,
which is not that great,
it wouldn't be a huge surprise
if there are complications.
My dad, he died on October, two years ago.
In August, he had a
10-hour surgical procedure.
I'm still not quite sure why.
They said it was for comfort purposes,
but that sounds a little extensive to me
for comfort purposes.
Nobody once said to any of us
what kinds of decisions
we would have to make
if complications ensued.
He was 81.
Thankfully I've thought about
this a little bit before
so I had already had
this discussion with him.
But nobody said you know,
we anticipate that this might go well but
it wouldn't be a huge surprise
if there were complications at his age
and his general health.
In particular, if you have
a parent or a loved one
in a nursing home, in fact we
have a term for these folks
which is not particularly complimentary,
but people would come
from the nursing home
to the hospital and back and forth
then we started calling
them frequent flyers
because I mean, we knew
they were gonna be back.
And rarely do we ever say to the family,
maybe not on this visit
but on the next one
or the one after this, you're
gonna have decisions to make.
Nobody, I mean, that kind of
heads up is really unusual
and I don't have confidence
that physicians will do that.
I'm a little more
confident that nurses will.
But this is where I think,
there's a huge place for you guys
to be a part of that conversation.
Question you wanna raise about that? Yeah.
>> Just a question.
I'm glad that you're bringing this up.
My thesis is actually gonna
be on end of life care.
I'm in the beginning stages of it.
So my understanding, I'm
a social worker student
and my understanding is a lot of times
nurses and other individuals
end up telling the families
you know, hey you need to prepare for this
instead of the actual physician,
and I'm not sure if that's really due
to more of the physician being busy
or kind of why that is, it's interesting.
>> Well, I'd say if that
were universally true,
that would be, I think, a
substantial improvement.
Because nurses are the ones who you know,
they're on the front
lines and they're the ones
who sometimes, they get it
before the physicians do.
And social workers are
usually not far behind.
And you guys, you earn your
keep navigating this stuff
at the end of life.
Because I suspect you've seen already,
I mean, there's huge family dysfunction
that comes out at the end of life, right?
I mean, there's more
dysfunction per square inch
in an ICU waiting room than in
a whole lot of other places.
And there's guilt and regrets
and all kinds of goofy stuff
that keeps people from
making good decisions
about the end of life.
And so they're looking to you to help them
sort navigate their way through this.
But I think there's a
really important part,
component to that.
Sometimes, physicians
don't empower anybody else
to make those, to have
those conversations.
And though I think physicians
training is getting better,
one of the things that the studies show
that people agreed on is
that there's a general
lack of education for physicians on this.
Now I think it's getting better,
but the pace of practice
doesn't contribute much to this either.
And most physicians are really
well trained to cure disease.
They're not trained to care
when cure is no longer possible.
Yeah?
[distant indistinct muttering]
>> Woman: I'm not sure that I
would have the popular view,
but in many ways, I think that it's unfair
to expect physician to [crosstalk]
I mean, I want a physician
that's gonna fight back disease
and be an expert in
that and not necessarily
be a focus on my family
issues and the rest of that.
I think we need to have
that taken care of,
but I don't think that's the
physician's role necessarily.
>> They're definitely
not trained to do that.
But as you know, that doesn't stop them
from forging ahead sometimes.
And granted, some physicians
do this really well.
Others don't.
That's a tough thing,
that's a tough conversation
to have with people.
And I think most physicians
actually distance themselves
from these kinds of conversations
as a survival technique.
>> Well, yeah and just as a focus.
I mean, their focus really
is to battle the disease
and to do everything they
can do in that arena.
And then one's that's lost,
then maybe they've lost a
little bit of their desire
to keep in the fight, but they're humans.
>> Again, I think this is getting better
but I think some physicians
take death personally.
I mean, oncologists have treated my dad,
they did not wanna give up.
And they probably should have
given up before they did.
I mean, they were still
suggesting experimental treatments
and research studies, protocols.
I told my dad probably four,
five months before he died
that you know, we know
where this is headed,
I mean, the only thing further
treatment will give you
is a little bit more time.
But nothing, and we knew that,
nothing was gonna turn this around.
But progressively, the cost physically
got higher and higher.
I mean, he had three
rounds of chemotherapy,
different regimens, and each one of them
killed him faster than it killed the,
it didn't do squat against the cancer
but it was killing him.
I mean, his ability to appreciate
the rest of his life
went down the drain.
I mean, I told him when he
could still make decisions
that you can tell the physicians to stop
whenever you want to.
And I said it would be okay to do that.
I don't think you realize quite how costly
this final surgery was gonna be
because he was in the
hospital for five weeks
and that's the last place,
that is the last place
you wanna spend a month of
your last three months of life.
>> Woman: Not to mention how
miserable he probably was.
>> Oh, it was terrible.
[distant indistinct muttering]
>> What do you think?
Do you think it's better to
just not go through that?
>> Well, I don't think it's
right to generalize like that.
I mean, it anticipates
where we're headed with this
but theologically I think
it's acceptable to say stop
before you die.
I don't think that we are required
to do everything at all times at all costs
to keep people alive.
The term we use for
that is called vitalism.
And the sanctity of life and vitalism
are not the same thing.
Now that raises a really
important question then
about under what conditions is that okay?
Because I suspect if your friend was 40,
maybe that's different.
Not strictly based on age, but you know
maybe if the prognosis is better
or the burdens and
benefits might weigh out
a little differently, then
that might be different.
And of course there are times when
it would be unconscionable to withhold
or withdraw treatments, right?
I mean, if people are gonna get better,
of course you treat them.
But you know, these are the cases
where the prognosis is clear and very poor
and they are you know, I mean,
they may not be imminently dying
but the trajectory has been set already.
I mean, with my dad, there was no doubt
what the end game was gonna be.
Eventually this was gonna overtake him.
And what that in-between time looked like,
we had a lot of say over.
Now I don't think you know,
I'm not sure looking back
we did all the right things,
which really helped me appreciate,
I mean I thought about
this a little bit more
than the average person, but doing this
in an academic setting and doing this
next to the kitchen table with my dad
is a very different experience.
So I mean, just be aware that you know,
it's just different when it's personal.
And so I get it, that families
have a hard time with this.
And that conversation was hard to have.
But it needed to be done.
Because the physician
certainly weren't gonna
have it with him, and I don't think my mom
had the stomach for it because I actually,
she needed to be at the
kitchen table too hearing it.
Yes.
>> Have you any indication that ODs
are any better than MDs at
these end-of-life issues
and then a second comparison?
>> I can't speak to that, I don't know.
>> Have you ever seen any difference
between physicians trained
at Christian schools
like Loma Linda or Baylor
versus public schools
like Irvine or Davis?
>> No, I don't think
there's a huge difference.
Physicians who have been trained,
I mean hospice physicians,
they get it.
It just depends on the person.
Some ethnicities, it's harder than others.
I'm not sure I can account,
we had a really tough time
with Middle Eastern physicians,
with them stopping treatments.
I'm not sure what accounts for that.
And some Asian physicians
had a really difficult time.
Asian families had a difficult
time stopping treatments.
African-American families
had a difficult time
with stopping treatments.
I mean, those are broad
generalizations but
it's a tough conversation to have.
And you know, but somebody's got to do it.
Yeah, Mike?
[distant indistinct muttering]
>> All hell breaks loose, yeah.
See, what I tell my seminary students is
if you wanna get better
at this, go hang out
with a hospital chaplain for a little bit
and go make rounds with him or her.
And ask specifically if you can sit in
on an end-of-life conversation.
Most chaplains would be thrilled
to have people come along,
sort of like a ride along
with the paramedics.
I don't know how many of my
students take me up on that
but that's another place to go, okay?
Any more on the pastoral side,
questions you wanna raise about that?
>> Do you think that,
I mean obviously it changes the way
you approach this, but like
age, the age of a person who's
[distant indistinct muttering]
if you're 21 and you get
diagnosed with cancer versus,
you know what I mean?
>> Yeah, I do think
that makes a difference.
I don't have a problem
giving treatments a
little more of a chance
the younger the person is
partly because a person's
ability to recover
from a really aggressive treatment
is better generally the younger they are.
I think there's also
something about you know,
my dad had lived a full life.
He accomplished everything
he'd set out to do.
I mean, the only thing
he had left to accomplish
was to beat this, which
he was not gonna do.
And so I think there's, yeah, I mean,
the 90th psalm tells us that our days
are 70 or 80 if we have strength.
And I think it's okay
to say you know, yeah, the
person's lived a full life.
And in general, I think it's
better that we are the ones
who say that about ourselves
and our loved ones,
or if we don't, the state will say it.
Because spending half of your expenses
in the last 12 months of your life
is an unsustainable system.
And so it's much better if
we managed this ourselves
than to force the state to do that.
But I would give a lot
more slack, I think,
especially with a child
than I would with an elderly person.
And I don't think that's
necessarily age discrimination.
Okay, anything else?
Okay, let's look to the moral
dimension of this a bit.
Seems to me these are
the fundamental moral values
from scripture that govern this.
And this is why I think the
debate over assisted suicide
theologically is this kind of a no brainer
because you know, you don't
take innocent human life
because it's God's sacred
gift and because ultimately,
at the end of the day, the
decision about the timing
and manner of a person's
death belongs to God, right?
And I would include taking
your own innocent life,
and I would say there's
just as big a moral problem
with suicide as there is with murder.
I would treat those situations
somewhat differently.
But in terms of being morally problematic,
I don't see a lot of difference in that.
Scripture also is clear
that we have an obligation
to protect the most vulnerable.
I find it ironic, sometimes tragic,
that if somebody in their
20s threatens suicide,
the full court press is
for suicide prevention.
But for somebody who is
understandably depressed
after a terminal diagnosis,
we shouldn't be super
surprised about that,
that basically all we offer
the elderly at the end of life
is suicide assistance.
And I would consider the
elderly, along with the unborn,
the contemporary equivalent
of the biblical widows and orphans.
In scripture, those were
used as a figure of speech
for the most vulnerable among us.
And I think the unborn and the elderly
have supplanted the widows
and the orphans today
as the most vulnerable among us.
And if we don't figure out
how to do healthcare better
than we're doing it, I'm
not thrilled about you know,
My Baby boomer generation becoming
the social security generation.
That's not gonna be a happy outcome.
Now to be a little more
specific theologically,
we know death entered as a result of sin.
Death is not part of
God's original design.
That's not the way it was intended.
But it is true that death is
a normal, natural part of life
because of the pervasiveness
and universality of sin.
In our culture, when they
say death is a normal,
natural part of life,
what they mean by that
is it's morally neutral.
But theologically, that's not true, right?
I mean theologically,
death is the ultimate indignity.
Right?
If you've walked with a loved one
through the end of life, there's nothing
particularly dignified
about the dying process.
In most cases, it's just downright ugly.
The dignity in dying
comes from how we cope
with our deterioration.
By the way, I'm not persuaded
that there's anything
particularly dignified
about an end run around that
through assisted suicide or euthanasia.
I think that the dignity
comes from how you face
the difficulties of the dying process.
So I think the idea,
I think theologically,
I think the idea of death with dignity
is a little different than
what the culture means by that.
I think you'd probably make
an argument that the term
death with dignity is almost
an oxymoron theologically
because of death being
the ultimate indignity.
So death is, we say, both
an enemy as a result of sin
and a normal, natural part of life.
However, the good news is that
death is a conquered enemy.
I mean, that's the last
word on the subject.
And were it not for the death
and resurrection of Jesus,
Paul suggests that we are to be pitied
because we have no hope.
Now the question is,
this is not breaking news
but what follows from
that is really important
it seems to me, and that is
if death is a conquered enemy,
then it seems to me that it
need not always be resisted,
that it's okay to say enough to medicine.
Now we got to be careful about the point
at which we do that.
But I told my dad, any time you wanna tell
these incredibly optimistic oncologists
that it's okay to stop, you can do that.
And just FYI, under the law,
whenever somebody says to stop,
that has an adult who's with
it, that has to be obeyed.
And if you don't, in California, here,
you might be aware of this,
in California, you know
what happens to a physician
who administers a treatment
against a patient's will?
You're in big trouble.
You know what kind of
trouble they'd get in?
You know what the charge is?
[indistinct chattering]
It's battery.
It's a battery charge.
Now there are exceptions to that of course
like if it's an emergency,
or if they're not competent
to make their own decisions
then that's different.
But most of the time, for a
competent adult to say stop,
if you don't respect that,
you're in deep manure.
Now I think where this
cashes out at the end of life
is that when a patient's
prognosis is very poor
and please, in walking through
this with your loved ones,
press your physician on the prognosis?
I mean, sometimes it's amazing to me,
I did a year's rounding project in the ICU
at a large Catholic
hospital up in the valley
and it was so rare that a physician
would actually write down the prognosis.
I mean, getting this out
of some of these physicians
was like pulling teeth.
And it's totally okay to
press them for the prognosis.
It's totally okay to
say if this was your dad
what would you say to him?
Or what decision would you make?
And don't let them dodge that question.
I think when this is case,
when the prognosis is
poor and further treatment
is not gonna turn this around,
then I think we ought to welcome death
as sort of the porch's step into eternity.
And I think it's wrong to
delay somebody's homecoming
because we can't let go of them.
And when their prognosis
is poor and medicine
basically can't do much
to turn that around,
then I think we ought to start
thinking less about miracles
and more about resurrection.
I think this third part,
I think making what is left
of life more burdensome
than beneficial for that
person is almost always wrong.
Let me give you an example of this.
We had consulted on
this case sometime ago,
it was a 95-year-old man,
he was in our ICU.
Now what he was doing in
ICU in the first place
is a good question,
But I don't think he
weighed more than 95 pounds.
He was at the end stage of
stomach and colon cancer.
And when the case came
to the Ethics Committee,
he was being prepped at
the family's request,
being prepped for, of
all things, a colonoscopy
for one last round of treatment.
I actually think you could
have held this guy up
to really bright light and
probably done the same thing
as the colonoscopy would have done.
[audience chuckling]
And one of the nurses came
to the Ethics Committee
and literally, this is how she put it,
she was just exasperated
with the whole thing,
she said why are we
torturing this poor man?
Now the family was in a
really interesting position
because they didn't know any of this.
They didn't know what a colonoscopy
was gonna do to this man,
not to mention the rest of the treatments.
Nobody had told them what they
were authorizing them to do
to this person who they
presumably called their loved one.
And you think surely we're
not gonna allow families
to authorize this kind of mistreatment,
which is what it was, mistreatment.
Now they were well intentioned,
but they were also neurotic
and unwilling to let go
and desperately needing a social worker
to come help them sort this out.
And finally we prevailed
on them not to do this.
But this guy was within
probably 30 minutes
of a very unpleasant experience.
And I will never forget
when my father in law,
he had had surgery, he had
a bladder tumor for years.
And in retrospect, we
probably should have just
left it in there but you
know, he consented sort of,
we pushed him at the
physician's assistance
to have this tumor, which is about
the size of a grapefruit, taken out.
And he had had complications
in the hospital
for like three or four weeks.
And I'm wheeling him out
as we're going to the car to take him home
and he can't even speak above a whisper.
And he motions to me, come close,
and he whispered in my
ear, he said don't ever
bring me here again.
I mean, it's just like
[imitates muffled explosion].
I got it.
We knew what he was saying, was I'm done.
I'm done with doctors and
hospitals and treatments.
He didn't put it this way,
but I think what he really meant by that
is I'm going to accept from God's hand
whatever days I have left.
And what came through
him between the lines was
don't delay my homecoming.
And so a couple of months
later, he had a stroke.
And against my better judgment,
we took him to the ER.
Sat in the ER for four hours
while the neurologist came in
and told him that he had a
stroke and sent him home.
I thought that was probably
one of the stupidest
things we've ever done.
So the next time he had a stroke,
we didn't take him anywhere.
And he had round the clock care.
I think eventually we
adhered to his wishes
to basically be left alone as
far as medicine was concerned
and to live out his
days as God's good gift.
And we were sweating
the days he didn't have
far more than he was, you know?
He was ready to go home.
I mean, home-home.
And it took us awhile to get that.
But I think you know,
had we authorized a whole
bunch more tests and treatments
and all of that, it
would have been bad news
for making his life more burdensome.
Okay, let me just do one
more thing real quick
and then we'll take a short break.
Here's the general, think
about this a little bit
over the break and then we
can talk about this further.
I think it's okay to withhold or withdraw
treatments that are life sustaining
when a competent adult requests it.
Under the law, you have to do that.
And whether they request it in writing
or orally is irrelevant.
Most of the time, a competent
patient will request it
when a treatment is futile
or if the burden outweighs the benefit.
It may do some good but
the burden so outweighs it
that it's just far
more, it's a net burden.
It increases the net level of suffering
that the patient endures.
All right, we'll take a break here.
When we come back, we'll talk about this
a little bit further and then I wanna deal
with some of the objections
to this that are often raised.
Some are moral, some are
more intuitive, okay?
>> Presenter: Biola
University offers a variety
of biblically-centered degree programs
ranging from business to ministry
to the arts and sciences.
Visit biola.edu to find out how Biola
could make a difference in your life.
[uplifting instrumental music]
