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Two days ago, we discussed on this blog about the value of advanced care planning from the angle of documenting and discussing one’s wishes.  I want to share another piece I came across from a Christian healthcare chaplain in Canada, in which he discusses not just the need for advanced planning but a spiritual perspective on the subject as well. 

We have all watched a TV drama in which a person’s heartbeat and breathing stop and someone jumps in, provides CPR and the person’s life is saved with no long term loss of vitality. Researches have looked at the success rates of TV CPR and compared them to the success rates in real life and you may be shocked to see the difference. The studies that I have looked at vary with TV success rates ranging from 67% – 85% compared to success rates in real life ranging from 5% – 15%. My point, the efficacy of CPR isn’t quite what we popularly think.

This is why some patients and/or their families are shocked when they are approached by a medial professional with the question, “Should your heart stop and should you stop breathing, do you want us to attempt resuscitation?” Patients and their families are shocked because given the popular conceptions as portrayed in the media; CPR works the vast majority of time so why wouldn’t I want that?

The statistics are much more complex than this though. For a healthy young person who experiences a trauma that stops the heart, success rates can be as good as 70 % but on an elderly person with multiple health problems, such as the folks that live in a Personal Care Home, the outcome is not at all hopeful. Studies have shown that the success rate is 0% – 1.7% in this population with the very few that do survive having a greatly diminished quality of life.

If you are older or have an older loved one who has recently been in the hospital or if paneling has taken place and you have had preadmission talks with someone at the Personal Care Home of your choice, the question may have been posed: “Have you given any thought to advanced care planning or do have a Health Care Directive?”

Most Personal Care Homes prefer that when a new resident is admitted that they have such a directive that state up front the wishes of the resident or proxy in regards to the kind of interventions that are desired in the event of a sudden or catastrophic decline in health. South Eastman Health has just established (July 19, 2011) a policy on “Advanced Care Planning – Goals of Care” that suggests three goals of care defined as follows: Comfort Care – Goals of Care and interventions are directed at maximal comfort, symptom control and maintenance of quality of life, excluding attempted resuscitation. Medical Care – Goals of Care and interventions are for care and control of the Patient’s/ Resident’s/Client’s condition. The consensus is that the Patient/Resident/Client may benefit from, and is accepting of appropriate investigations/interventions that can be offered excluding attempted resuscitation. Resuscitation – Goals of Care and interventions are for care and control of the Patient’s/Resident’s/Client’s condition. The consensus is that the Patient/Resident/Client may benefit from, and is accepting of appropriate investigations/interventions that can be offered including attempted resuscitation.

This can be a difficult discussion and most of the time it is entered into with great sensitivity and folks are given as much time as needed to process the information and make a decision. But making decisions is much easier when we have accurate information that we trust.

The issue of DNR, do not resuscitate, is often misunderstood, as the author indicates.  For most people dying, CPR is ineffective and all it usually does is cause tremendous harm to the body of the deceased and trauma to the family that witnessed the resuscitation attempt.  In my early days in chaplaincy, I recall one such situation in which I was calling to offer condolences only to be harangued over the fact that the DNR had not been in the house and the daughter ended of seeing her mother’s bones broken during the futile attempt at resuscitation.  I can only imagine how that image must still be haunting her years later. 

But as people of Faith do we have an obligation to do everything humanly possible to preserve life? In the Christian Faith, there is a conviction that comes from our Sacred Text: the Bible, which goes something like this: God alone has the power and right to give life and to end life, therefore, as persons created in him image, desiring to live under his love and authority, we must leave matters of life and death in God’s hands. “Thy will be done…”

Of course within the Christian Faith there is disagreement to what this conviction means. Some insist that this means that we need to trust God and God alone with our life that we shouldn’t be engaging the medical system at all for to do so manifests a lack of trust in God’s loving care. There is such a group right here in the Steinbach area, devout, God-fearing, serious people who believe with all their hearts that this is God’s will.

There are others who believe that God has invested humankind with intelligence and wisdom and he expects us to use that for our mutual good. Because this is so, the advances that are made in the medical sciences are seen as a gift of God to be accessed and used for the health and well-being of our bodies. The majority of those who live in our region are of such a conviction. But does this conviction demand that whatever can be done should be done? Does it demand that a Christian person accept all medical interventions, until none of them work and death ensues?

Is there a middle ground? Is there room in “God’s will” for serious believers to come to different conclusions on this matter? Probably. So how do we find a place along this continuum that we can embrace with conviction and without fear? There is a principle in the Romans 14 that I believe is helpful in this regard. This chapter of the Bible is dealing with matters of conviction, not clearly stated to be right or wrong in the Bible. The question before us seems to be one of those.

The principle, “everything that does not come from faith is sin”. In other words, when God’s word gives no absolute guidance on a matter, it is a matter of conscience and believers should seriously make a decision in regards to what they believe on the matter, and then live out that decision in faith towards God. To violate one’s conscience in these matters is sin. A complementary principle, also taught in this same chapter is that we ought to respect each other, even if we come to different conclusions on these kinds of matters.

So as regards to whether a Christian should have a Health Care Directive or an Advanced Care Plan, as far as I can discern this is a matter of conscience. Each of us needs to carefully and prayerfully make this decision guided by our understanding of the Lord’s will as it comes to us through the Bible. Some will be convicted that they should not engage the medical system at all, trusting God entirely to provide for the needs of their body and health. If they do this in faith out of conscience towards God, I respect and honor their faith and the decision that grows from that faith.

Others will engage the medical sciences to one extent or another: some looking for absolutely every possible intervention until death and others believing that they have the prerogative to say “no” to certain treatments offered, if those treatments do not reflect their personal goals and desires. Those who do this out of conscience towards God in faith should be respected as well.

Do I have a Health Care Directive? Not yet, but I am planning to make one soon so that if my wife and children are ever placed in the position where they need to know what I would want they will know with clarity. In the final analysis, “All the days ordained for me were written in your book before one of them came to be.” (Psalm 139:16) God is in control and the best possible posture is to live under that control by faith.

He presents a very interesting theological argument for advanced care planning.  If our decisions come from a place of faith, perhaps the decisions are appropriate regardless.  I think this could be a very interesting approach for spiritual care providers to consider in working with families.  We are not in a position to judge.  Sure, if it were a situation in our own families we might act differently.  Yet, when it comes to supporting others, if we can see their decisions for what they often are, decisions of love and faith, perhaps we will better be able to support them in the process.  This is speculation on my part, but this is all part of the chaplaincy struggle of being true to one’s own faith while being able to provide and care for people of others beliefs, cultures, faiths and religions.

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