Article Issues Analysis: End-of-life - The dying process By ERLC Apr 10, 2014 End-of-life issues are the various topics and ethical concerns that arise during the time surrounding death. ERLC is developing issue analysis briefs to address a broad range of issues, from decision-making to euthanasia, that concern the end of life. The purpose of this brief on the “dying process” is to provide a broad, general overview on how Christians should think about death and dying. What is the Christian view of death? Death is common, but not natural. Death entered the world because of the sin of one man, but was conquered by the death and resurrection of Jesus Christ (1 Cor. 15:21). Death is so unnatural that God sent his one and only Son as a sacrifice so that we might have life (John 10:10; Revelation 1:18). Death should therefore be considered an enemy – but a defeated enemy. Although this enemy may win a temporary victory over us, those who know Jesus will ultimately be victorious. We can therefore struggle against death knowing that when we lose our life we will gain it back in the resurrection. We do not need to fear death, nor hold on to life too tightly. We can trust that God is in control and that for those who love God all things work together for good (Romans 8:28). What does it mean to say that a person is dying? When we say that someone is dying, we mean that they have entered the dying process. The dying process is the final stage of the living process, since those who are in the process of dying are still in the process of living. Those who are dying must therefore be treated with the same respect and consideration due to all living human beings. Jesus said, “By this all people will know that you are my disciples, if you have love for one another” (John 13:35). One way that we can express love for the dying is to show that we are grateful for their continued life. As the philosopher Josef Pieper reminds us, loving a person is a way of saying, “It’s good that you exist; it’s good that you are in the world!” Those who are nearing the end of lives need to know that it is good that they exist, that it’s good that they are still in the world. And they need to know that we are with them, loving them, as they enter this final stage of their lives. How do we know when someone has entered the dying process? When a person suffers a potentially fatal threat to their health (e.g., disease, injury), their impaired condition may be either reversible or irreversible. If the condition is reversible, appropriate medical intervention and treatment exists that may possibly restore a person to a state where they are no longer in imminent danger of dying. However, if no effective intervention or treatment is possible, the condition is irreversible (i.e., terminal) and the impaired condition will lead to death. This is what is meant when we say that a person is dying, or has entered the dying process. Two key considerations in end-of-life issues are the person’s (1) nearness to death and (2) their ability to interact with the world. Nearness to death – Although we may not be able to know with certainty, we can often determine how near a person is to death, whether death is imminent or non-imminent. Imminent is when a person is expected to die in a relatively short period of time, such as hours, days, or weeks. If a person is not expected to die for months or years, then death is considered to be non-imminent. Ability to interact with the world – A person in the process of dying may be either conscious (or potentially conscious) or permanently unconscious. A person who is conscious and in the dying process maintains the ability to communicate with those around them and express their wishes for continued medical intervention and treatment. A person who is permanently unconscious and in the dying process must rely on other people to determine their level of care and continued treatments. How should people in the dying process be treated? Whether death is imminent or non-imminent, our first consideration for dealing with people in the dying process is that we take no action with the intention of hastening the end of their life. As bioethicist Gilbert Meilander explains, “Allowing to die’ is permitted; killing is not. Within these limits lies the sphere of our freedom.” Within these boundaries lies four types of care that we owe the dying: curative care, symptom care, comfort care, and respect care. Curative care – Life is a gift from God that we may not choose to discard. When life can be continued, we must choose that option. Medical intervention that restores health and reverses the dying process should therefore be the first option. Symptom care – In some situations, a person may not be in imminent danger of dying yet may have a fatal condition that is not reversible. For instance, a person may have an inoperable cancerous tumor on their lungs that will eventually cause their organs to shut down. While they are in the non-imminent dying process, they may suffer symptoms such as shortness of breath that requires medical intervention, such as artificial respiration. Out of respect for life and to prevent unnecessary suffering, all necessary symptom care—a form of palliative care—should be provided until death become imminent. Comfort care – People in the dying process should not suffer needlessly. When death becomes imminent, palliative care should shift from symptom care to comfort care. The main distinction is that comfort care focuses on providing direct relief from the stress and pain of dying. Comfort care is provided to make the last state of dying as comfortable as possible. Respect care – The dying process often leads to deterioration of the body. Because a person is often unable to care for their own bodies, they may feel a loss of control. Our duty is to provide such care for people unable to take care of themselves in a way that restores their sense of dignity. We should, for example, ensure that their bodies are adequately cleaned and that they afforded a level of decorum and privacy from unnecessary exposure. No matter what stage a person is in the dying – or living – process, respect care should be provided to all who are in need. (Note: Because of the broad range of ethical issues that arise when dealing with people who are permanently unconscious and in the dying process, a separate issue analysis will cover this topic in more detail.) How should we prepare for the dying process? The most important step an individual can take when preparing for the dying process is to ensure that they know Jesus Christ as their Lord and Savior. As the Apostle Paul says, “For the wages of sin is death, but the free gift of God is eternal life in Christ Jesus our Lord” (Romans 6:23). We have no reason to fear either death or the eternal consequences of our sin when we believe in Jesus (John 3:16). The second step is to ensure that we have made every effort to be at peace with those we are leaving behind (Romans 12:18). If someone has sinned against you, tell them their fault and attempt to reconcile (Matthew 18:15). Forgive those who have harmed you and let go of any anger and resentment you may harbor in your heart (Matthew 6:14-15; Proverbs 19:11). The third step is to recognize that we do not enter this world alone and, if we are blessed, we will not leave alone. Just as families are involved in birth, they should be involved in death. While we do not want to put unnecessary burdens on our families when they will be going through a difficult period of sadness and grief, we should include them whenever possible in the ethical and medical decisions that will need to be made. Communicate to your loved one the principles and priorities that should guide your end-of-life treatment. But don’t use this time as an opportunity to exercise unrestrained self-autonomy. Explain to them your wishes, but allow them – within ethical boundaries – to have some say in how you will be cared for in the dying process. (For more on this point, see the issue analysis on end-of-life decision-making.) The last step is to cast your anxieties upon Jesus (1 Peter 5:7). Even for the most faithful believer, the dying process can be one of the most anxious and frightening periods of our life. Waste no time chastising yourself for the failure to be strong, but simply give your weakness up to God. Turn to his promises, found in the Bible, and to his people, the Body of Christ, for comfort and peace. What resources are available to better help me understand this issue? ERLC Resource: ERLC is creating issues analyses on several end-of-life topics. Website: The Center for Bioethics and Human Dignity (cbhd.org) Book: Basic Questions on End of Life Decisions: How Do We Know What's Right? (BioBasics Series) Dónal O'Mathúna, John Kilner, et al. (Note: This helpful, brief book was the primary resource for this issue analysis.) Book: Bioethics: A Primer for Christians by Gilbert Meilaender Note: Referrals to other organizations should not be construed as endorsements of all of the activities or resources of those organizations.