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Volume 9, Issue 5: Medicus

Advance Directives

John Grauke

The yearling stood in the middle of the clearing, legs splayed in front, neck low, head hanging, tongue visible in his open mouth as he heaved great draughts of air into his chest. He cast furtive glances at the three openings to the corral that held him and before he could recover a sliver of his drained strength he cast himself, legs flailing, at the nearest of the openings. As he covered the distance to the expanse of freedom beyond, a boy stepped in front of the opening. Again for the who knows how many times he corrected his path and headed to the next opening only to have it obstructed by yet another boy stepping into his path. Finally exhausted, he dropped, first to his knees and then to his heaving side. At last he could rest, too tired to do otherwise, predicament unsolved, freedom unattained, until his strength returned enough to begin again.

This scene has flashed through my mind many times as I have cared for people near the end of their long life. They are the deer struggling to reach the opening. I am the boy blocking their path with my medical armamentarium. People, like a marathon runner, seem to reach the end of the race tired, no matter how well or poorly they have run. I am sure Solomon had this in mind when he wrote the 12th chapter of Ecclesiastes. This scenario leads doctors, patients and their families to talk of what can be left undone as often as what can be done.
Advance directives (a/k/a "Living Wills") allow people the opportunity to make their wishes known regarding end-of-life decisions. They provide an effective way for patients to maintain their autonomy should they become incapable of decision making because of serious illness. Health Care Proxies state that someone else may make health care decisions ("serve as my proxy") if the individual becomes "incapacitated" or "incompetent". As medical technology has increased over recent decades, so too has the complexity of end of life decisions. Initially these questions were taken to the courts in individual cases and case law developed. With the celebrated case of Nancy Quinlan in the 1970's, the public became acutely aware of and concerned about the legal and ethical issues associated with a prolonged death. From these concerns, legislation began to develop in many states to provide patients with more control over their own death. In December of 1991 the federal Patient Self-Determination Act was created to ensure that patients were informed of their right to accept or refuse medical treatment and their right to execute an advance directive. The Act requires that written information concerning these rights be given to all adult patients upon admission to the hospital or nursing home, enrollment in a HMO, or upon receiving initial care from a home health agency or hospice program. Compliance with the Act is required for participation in the Medicare program.
Advance directives have economic implications. People who die without them average $65,000 more in medical care costs than people who die with them. If you or someone you love should become incapacitated and end up on life support systems in an Intensive Care Unit, the catastrophic limits on an insurance plan can become exhausted, leaving your estate vulnerable. The legal road to removing a person from life support can be a costly and time-consuming undertakingethically, emotionally, and financially. Christians should prepare for death, and thinking about advance directives may help.
Being a Christian is the sine qua non of end of life planning. Believers have no need to fear death. One of the most common images used in describing death of believers is sleep. "Our friend Lazarus sleeps, but I go that I may wake him up" (John 11:11). "But let me lie with my fathers" (Gen. 47:30); "Many bodies of the saints who had fallen asleep were raised" (Matt. 27:52); and, "But I do not want you to be ignorant, brethren, concerning those who have fallen asleep" (1 Thess. 4:13). Many of the passages describe "falling" asleep implying rest at the end of a tiresome journey, and all anticipate awakening on the other side.
In this connection, it is instructive to observe the beautiful and comforting manner in which Scripture speaks about the death of believers. If you are a Christian, your death is "precious in the sight of the LORD" (Ps. 116:15); you will be "carried by the angels to Abraham's bosom" (Luke 16:22); you will "be with Me in Paradise" (Luke 23:43). We are "having a desire to depart" (Phil. 1:23) in order to be with Christ and to be present with the Lord (2 Cor. 5:8), knowing that the place we go to is "far better (Phil. 1:23) for we will be resting in the Lord.
This sleep to which Jesus refers is not an "intermediate state" of unconscious repose. You are asleep to this world but awake to the presence of Christ (2 Cor. 5:8; Rev. 7:15-17). Like the thief on the cross, the day you die you will be in paradise with Jesus worshipping Him with a joy we cannot now comprehend.[*]
The deer bolted awake, bitten by the memory of his plight. He rose to wobbly but determined legs, spun around and trotted in a spiral path eyeing each escape opportunity as he passed. One of the boys seemed to stand aside and he shot through the opening, free at last.

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