"I just don't want him to suffer anymore..."

Almost always when I walk into a patient’s hospital room, the first thing I do is turn off the TV. Sometimes, I'll turn off the roommate’s TV, too. (Every room has two, you know.) Have you ever tried to maintain interest in someone’s diarrhea when right behind your head there’s a John Wayne marathon on AMC ?

Well, for whatever reason, today I left it on as I walked up to the bed in critical care. And sure enough, like the TV-zombie child of the 70’s that I am, I was soon fighting desperately to concentrate on my patient’s kidney failure instead of the breaking news on the Today Show: “NYC studio offers naked yoga.” That’s right, naked yoga. Fig leaves? Shame? Those are so Garden-of-Eden. Here in America, we gonna let it all hang out.

Suddenly, it became clearer than ever before that all a man needs to understand America is Isaiah 5...

20 Woe to those who call evil good, and good evil;
            Who substitute darkness for light and light for darkness;
            Who substitute bitter for sweet and sweet for bitter!

21 Woe to those who are wise in their own eyes
            And clever in their own sight!

22 Woe to those who are heroes in drinking wine
            And valiant men in mixing strong drink,

23 Who justify the wicked for a bribe,
            And take away the rights of the ones who are in the right!

24 Therefore, as a tongue of fire consumes stubble
            And dry grass collapses into the flame,
            So their root will become like rot and their blossom blow away as dust;
            For they have rejected the law of the LORD of hosts
            And despised the word of the Holy One of Israel.

Patients want TV’s in their rooms for the very reason I turn them off.

All of America, especially healthcare, has joined forces to call evil “good” and good “evil.” You simply can’t think soberly about life, let alone the relationship between sin and suffering, while all 60 channels, 24 hours a day tell you if it makes you happy, it can’t be that bad. But of course no one, except maybe an occasional nurse’s aid or housekeeper, (certainly not chaplains, doctors, hospital attorneys, or administrators) wants to get mixed up in Godly sorrow, deathbed conversions, or the Holy Spirit’s conviction of sin, righteousness, and judgment.

Is that constant pain making you think about how you’ve treated your wife for the last 40 years? Just turn on CSI and you’ll soon feel better about yourself. Thinking about how you wouldn’t have gotten cirrhosis if you had honored your mother and father? Hey look, Brittany Spears has a new boyfriend! Wondering if your pneumonia has anything to do with your greed or failure to discipline your children? You can worry about that after the Breaking Bad season finale.

I disciplined my eyes to look away from the anchor-babe calling evil “good” and good “evil”, demonstrating the exercises she would do if she were in a naked yoga class. Instead, I finished tending my patient. But before I made it back to the nurses station, Isaiah 5 washed over me again with the overwhelming reality that I live and work in a world that’s completely upside down, blind beyond all natural hope, busy validating every form of wickedness, and doggedly opposed to righteousness.

Take, for example, the recent uproar over the method used to execute a convicted rapist and murderer in Ohio. It turns out drug companies have gotten squeamish about their wares being used in state executions. Accordingly, some now refuse to sell their drugs for death penalty purposes, forcing Ohio authorities to turn to an alternative two-drug combination that reportedly has never been used in executions. Departing from the tried-and-true methods was too risky, opponents claim, and predictably resulted in the convict suffering unduly.

There’s just one problem with this argument. The cocktail is actually so well-tested it’s ubiquitous. The effectiveness of this combo is so universally accepted as to be standard of care, despite the contrary thunderings from Mt. Harvard. I will grant that the combination may be new to the criminal justice arena, but in hospitals, nursing homes, and hospice houses across the land, keeping these drugs on hand approaches the inviolability of paying the cable bill.

You see, this is the combination of drugs -- opioids and benzodiazepenes – that doctors use on a daily basis—many to kill their patients, but all to treat the very symptoms Dennis McGuire supposedly unjustly suffered from: air hunger and agony. In fact, every doctor I know (who treats dying patients) uses those very drugs in dying patients to alleviate “air hunger” and “agonal respirations”, largely for the sake of the on-looking family members “who just don’t want him to suffer anymore.”

Avoidance of suffering is the only good we know. It doesn’t matter if we’ll have to call evil “good," just so long as there’s no perceivable suffering.

A young friend studying to be a pastor recently asked me if the first goal of medicine wasn’t to preserve life. “No,” I had to answer. "Nowadays, it’s to eradicate suffering.” Everything else takes a backseat and the ends justify the means.

Did the dilaudid deaden the patient’s conscience during his last few hours left to repent?

Just so long as he didn’t feel any pain.

Did the valium take away his chance to say “I’m sorry”?

Just so long as he was comfortable.

Did the morphine drip make him die a day sooner than he would have otherwise?

I just didn’t want him to suffer any more.

We doctors are heroes and valiant men in mixing strong drink, and yes, these drugs do often hasten death (i.e. kill) by suppressing respiratory drive and other functions. Everybody knows it and many exploit it. I wish the ethicists and Christian Medical and Dental Society could successfully assuage my conscience when they bring out the principle of double effect, reassuring me there’s no moral problem as long as the intent is not to hasten death, but rather to treat pain and suffering. But I can’t seem to forget the look on that veteran oncology nurse’s face as we talked outside the room of a man taking far longer to die than any of us expected. Giving perfect voice to the universal wisdom of the medical world, she insisted, “You need to order some Ativan so we can get this over with.”

We can quibble over the doses they used in Ohio and how to perfect the process in the future, but here is the real point of irony, the most tragic revelation about our culture: we celebrate the use of two drugs to kill our parents, grandparents, and patients while we march, protest, blog, and sue when the same two drugs are used by God’s ordained authority to kill a man who raped and killed a 22-year old woman and her 30-week-old unborn baby. We applaud ourselves when we use morphine to shorten our mother’s dying process from three days to six hours, but we tear our clothes in outrage and take to the streets when it takes 25 minutes to serve justice to a rapist and murderer.

You say, “But don’t you see, Dr. Spaetti? In the one case you’re alleviating suffering while in the latter case you’re cruelly inflicting it.” With the same two drugs? Seriously? Oh, how wise we are in our own eyes!

The truth is, our god is anesthesia – anesthesia of the body and particularly of the conscience. Any level of sober awareness is too much for us. How else can we explain the complete conquering of our nation over the last 20 years by prescription pain killers and sedatives? I would venture that not one family in America has escaped the devastation of their dominion.

We want to avoid even the slightest itch, and if it means we have to reject every last law of the Lord of Hosts, we’ll do it. As our society smothers its last traces of its Biblical heritage, despising the word of the Holy One of Israel, we lose all memory that our very salvation was purchased through suffering, that Jesus tasted death so we wouldn’t have to bear it for eternity, and that we should rejoice to “share the sufferings of Christ” (1 Peter 4:13), “filling up what is lacking in Christ’s afflictions” (Colossians 1:24).

Adam Spaetti

Adam came to Bloomington in 1995 for undergraduate studies at Indiana University. During the second semester of his freshman year, Adam gave his life to Jesus Christ. He has practiced Internal Medicine in Bloomington since 2008. When not tending the sick or spending time with his family, Adam's greatest joy is worshipping and serving as a ruling elder with Clearnote Church of Bloomington.

Comments

Dear Joe,

God bless your work with this family, dear brother. It can be tough slogging.

BTW, the post was written by an elder of our church, Adam Spaetti.

Love,

Adam,

Thank you for this post, brother. This topic needs to be shouted from the rooftops. Every pastor faces these situations and, sometimes because of ignorance or, more often, because of a combination of ignorance and complicity, says nothing to suffering patients or their guardians. Do some more posts. Give some specifics. What do pastors, patients, and guardians look for in the hospital room? Are we to be skeptical of all hospice care? What questions to ask of the doctors, nurses, parents, children? What does morphine do? What does Ativan do? When is their use legitimate? When should we be skeptical of or refuse their use? What are good resources a layman can read to prepare for and understand these medical/ethical situations? How can pastors prepare their flocks for their "nosiness" (as many perceive it) in medical situations?

Love,
Andrew

I was wondering if any here have read "Compassionate Jesus" by Christopher Bogosh and if so what do you think he contributes to the discussion?

I have a friend who lost her father to cancer recently. She had come to Christ as an adult and was very concerned about his spiritual state for many years. At the end when he was receiving hospice care, she was in a different state. Her brother was updating her on his care, and they were very upset that the father was in so much pain and suffering, thinking that the caregivers were not doing enough. I suggested to her that the suffering her father was going through at the end might lead her father to repentance. It was the first time she had thought of that, and it became a tremendous comfort to her. Her father died within a couple of days of this conversation, and she was told that he had tremendous peace in his last hours. Our conversation gave her hope that his peace was real and eternal.

Dr. Spaetti, count me somewhat jealous that when YOU visit a patient, you've got carte blanche to turn off the idiot box! :^)

when I visit, I should ask more often....

Bev,

I have not read that book. After I saw your question, I looked it up and read the description of it that appears on any number of the websites selling it. In that description we're told the author challenges the "pervasive prolong life at all costs mentality." While that mentality may have been more commonplace years ago (I do not know), I've never found it to be anywhere close to pervasive. Present, yes. Pervasive, no.

Instead I much more often encounter a readiness to withdraw care because a life is judged to have no "quality." Everything has become subjective. One of my hardest recurring tasks has been trying to open family members' minds to the idea that human life possesses inherent quality by virtue of the fact that we're made in the image of God.

Celebrating the imago Dei does not, however, mean that I believe everything that technology will allow should be done in all cases to sustain life. I may attempt a future post on this difficulty, but I have much more practice at addressing this at the bedside than in writing.

For now, I will say that I am unavoidably skeptical, in a culture that increasingly calls death a friend, of receiving a full picture of Christ's compassion from a hospice nurse, especially if he doesn't keep the danger of the "prolong life at all cost mentality" in proper perspective to the much greater evils that do pervade modern medicine.

But thank you for bringing the book to my attention. If I can find time to read it, perhaps I'll write a review here.

Dr. Spaetti,

Thanks for your response. At the risk of potentially not giving the whole picture here and misrepresenting the author while not writing a book review; the author did NOT seem to imply that the medical profession as a whole was interested in prolonging life. His approach was more focused on people who are afraid to die or their family members don’t want to let go and fight it tooth and nail when every indication is that there is no hope; like the stage 4 cancer patient who has exhausted the gamut of cure options and is given weeks to live but still doesn’t want to give up looking for a cure.

The author does bring up issues like “brain dead” and speaks about the fallacies of declaring death based on such a definition.

Though the author is thankful for the care that hospice gives, he does not agree with their ideology of death:

“The butterfly (a Hospice symbol) symbolizes a transition from death to this new stage of existence, which is up to you! ….. NHPCO* and hospice’s recasting of death is a tragedy because it creates a barrier to the message of the exclusive hope embodied in the year of the Lord’s favor.” pg 124-125

The gist of what I took from the book was more about how to die well as Christians in light of the resurrection of our Lord.

It is a short book, less than one hundred fifty pages.

I would look forward to a review if you would find time to read the book and write a review.

Thanks again for your response.

Bev C.
* NHPCO stands for The National Hospice and Palliative Care Organization

Dear Bev,

You've peaked my interest. I'll try to get my hands on a copy.

Warmly,

Dear Brother Andrew,

Thanks for the encouragement. It's funny how writing begets writing. Having gotten over the hurdle of making my first contribution to this blog, I find myself more motivated to say additional things than I ever remember being.

Your questions are good ones, and I'd like to have a go at a few of them sometime. And yet some things are difficult, if not impossible, to codify or systematize. Tim has said it before, and it really is true. Each difficult case brings with it so many complex twists and turns that you have to consider each one individually.

But there are rules of thumb and ways to train our senses. I'll see what I can do as time allows.

Love,

I imagine that if you hear it said often enough, "I don't want him to suffer anymore" starts to sound like "I want to stop seeing his suffering."

Dr. Spaetti wrote:

>Did the dilaudid deaden the patient’s conscience during his >last few hours left to repent?

>Just so long as he didn’t feel any pain.

>Did the valium take away his chance to say “I’m sorry”?

>Just so long as he was comfortable.

Dear Dr. Spaetti,

Would you feel differently about alleviating a patient's suffering when death was imminent if you knew that:

*He or she was a practicing Christian and had made a final confession of sin to a priest or minister according to his or her denomination?

*He or she had already made peace with as many relatives and friends as possible already; therefore, there wasn't anyone to to say "I'm sorry" to.

*Although he or she was unable to speak, it was clear by facial expression, gestures, or other body language that he or she desperately wanted relief from pain?

Thanks,

Sue

I appreciate what you have written about this topic, Tim. It has helped me immensely in the last month as I have had to counsel a family through (and continue to counsel) a doctor's strong opinion that the machines be undone because "this isn't life."
 
The call to suffer seems sadly neglected not only on the part of the one in the hospital bed, but for those who have to sacrifice time, tears, money, and years caring. Pouring out one's life so that another might live is a great Gospel witness and one that we should not just do, but be eager to do.
 
Thanks again.
 
-joe?

Dear Sue,

Good questions. While it wasn't emphasized in my post, I did indicate that I, like all other doctors, do routinely use these medicines to relieve pain at the end of death. Even though I don't think alleviating suffering is the only or even greatest calling of a doctor, I do think it's important.

My concern expressed in the lines you quoted was the interference these drugs have with the important work of dying well. Even for a repentant Christian with all the goodbyes said and no known grievances to settle, there are other good ways to spend his dying hours than in a drug-induced oblivion (praying or listening to his wife sing hymns comes to mind). I can't make people do that work, but I can try to encourage it. In a culture with no doctrine of suffering, that's almost always a hard sell if pain is involved.

But whether they will or won't buy into that final work in this life, I still use the drugs, trying to strike the best balance I can between consciousness and comfort.

Sincerely,

Dr. Spaetti,

Thank you for your comments.

I join others in hoping you will write more in this area. I have attended the deaths of my mother, my father, my father-in-law, and my nine-year old daughter. “Attended” here means I was actively and intimately involved in patient advocacy, sometimes for months, as they moved inexorably along a path that ended at Heaven's gate. All are Christians; three departed this world in their own homes, not in hospitals.

With this much “experience,” I am still appalled at how little help I found – actually no help at all – in managing the spiritual issues attending the medical care of end-of-life patients. I judge hospital chaplaincies (in my experience, mind you) to be utterly worthless at best.

In a different and recent blog post, the discussion turned on the desirability (where possible) to bring dying back into the home. Much medical technology that might be deployed in the home for a patient as he is dying is fraught with ethical and spiritual issues that are not obvious on the surface. Because you can meld knowledge of the medical technology (including pharmacology) and orthodox spirituality and ethics, you could provide a much needed service to Christians who wish to be equipped to serve their elders and other family members at a time when getting up to speed on these issues presents a very steep learning curve.

My first (and, thus far, only) personal encounter with morphine occurred 17 years ago when I got some doses of it while having a heart attack. My physician and I were in the ER, discussing which clot-busting drug to deploy after other folks were satisfied I had no stroke-related processes underway.

In the midst of this discussion, I closed my eyes (they were so heavy!), telling my Dr. John (a mature Christian himself) that I wasn't asleep, just wanting to stop fighting heavy eyelids. And a short time later, I said to him, “John, I'm not worried about this, but I thought it best to tell you that I don't particularly want to breathe any more. I am breathing, but I'm doing so because I suppose it's a good thing to do.”

He broke out in laughter, and said, “Oh, yes, Bill! By all means keep breathing!” He went on to explain the effects of the drug, that it was likely enhancing oxygen uptake, making the “urgency” to breathe to recede. We resumed our discussion of streptokinase verses tissue plasminogen activator, reached a decision, and 30 minutes later the heart attack was in the rear-mirror, receding rapidly. But, I've never forgotten how appealing, how comforting, how … well, narcotic morphine is.

Thank you, Adam.
Love,
Jeff

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