CASE STUDY Nov 2017. Christian Journal for Global Health 4(3):53-59 Death in a Mission Hospital James V Ritchiea a MD, emergency medicine, lecturer, Kabarak University, Kenya Abstract Medical missionaries may struggle with the proper understanding of their roles in the death of their patients. To better grasp a biblical concept of death, medical missionaries should understand God’s plan for death and also understand both God’s sovereignty and their own free will. Missionaries should prepare patients and their families for impending death while observing cultural sensitivity. Cultural objections to discussing impending death may be addressed by emphasizing the Christian understanding of earthly death and eternal life, and by honoring the passing of the believing patient. A New Work We had started a good work. We had taught advanced cardiac resuscitation to our new residents and interns, and placed our newly-donated defibrillator on our shiny donated code cart in the ward. This was a new capability for PCEA Chogoria Mission Hospital in central Kenya, and we were very excited. Within hours of starting the program, the defibrillator was used, and the patient was saved! Hallelujah! More cardiac arrests occurred during the next week, and the code responses rapidly became more coordinated. Most codes ended in death, of course, but we could finally do something about the death of our patients instead of simply pulling the curtains with embarrassment and putting the body quietly in a side hallway. Now, even the failed codes were a victory of sorts. But one morning, one of our outstanding Family Medicine residents spoke quietly to me during rounds. “You know, Daktari1, the nurses are calling us for every single death, even deaths that are anticipated. Last night, we coded the 95-year-old man who had a large stroke at home three weeks ago and was brought to us completely comatose and covered with bedsores. This does not seem right.” The resident was correct. We had introduced a powerful new tool but had not taught the concept of Do Not Attempt Resuscitation (DNAR). As a result, we were engaged in a futile attempt to revive people who should have been allowed to die in dignity. Furthermore, we were using supplies needlessly and assaulting our patients with electricity and rib-fracturing chest compressions. Chagrined, I thought, “At least this is easily remedied and hasn’t gone on for too long. We will speak to the nurses and doctors, and introduce the concepts of DNAR and advance directives.” I began immediately speaking with our charge nurse about those ideas and asking her advice on how to teach the ward staff. But I was surprised by her response. “Daktari, we cannot do that. We cannot do everything for some patients and do nothing for others. That would be very disrespectful and would make us seem uncaring or appear to choose who should die. Also, it is not welcome to speak with 54 Ritchie Nov 2017. Christian Journal for Global Health 4(3):53-59 the family about death before it occurs. Doing so would make us seem to be wishing for the death.” I was stuck. I had no idea of how to deal with these cultural objections. But I knew that in our mission hospital, we were not “doing death” well. “Am I a Bad Missionary?” Months beforehand, a colleague had come to lunch in a distraught condition. She was an outstanding obstetrician-gynecologist and was also new to the mission field. We asked her what was wrong. “You have to understand. In the US, I was in private practice for nine years, and I never lost a single patient. Not one. But in the last 24 hours, I have lost four—in the OR, in delivery, and in the ward. I don’t know what to do. Am I a bad doctor? Am I a bad missionary? Is God trying to tell me something? I am afraid to touch another patient. Who will die next?” After learning the details of the cases, we tried to comfort her, assuring her that she was a fine physician and had treated her patients very well. But we also realized that in the minds and expectations of our doctors, we were not “doing death” well. Paul and Questions The apostle Paul expressed his ideas about his own death very clearly. In his letter to the Philippians, he wrote, For to me, to live is Christ and to die is gain. But if I am to live on in the flesh, this will mean fruitful labor for me; and I do not know which to choose. But I am hard- pressed from both directions, having the desire to depart and be with Christ, for that is very much better; yet to remain on in the flesh is more necessary for your sake. (Phil 1:21-24, NASU, emphasis added) Paul was mentally whole, but was glad to look forward to his own death. He even preferred death and seemed disappointed that he had to continue to live on a while longer. In our mission hospital, with regard to the problems on the ward and the expectations of our colleague, our concept of death did not match very well with Paul’s concept of death. We realized that we needed to return to the Word to re-orient our ideas of death. We decided to ask some questions about death and answer them from the Bible. Question 1: Who is the Author of Life? The answer to this question should be obvious to us. In Genesis God said, Let the waters teem with swarms of living creatures, and let birds fly above the earth in the open expanse of the heavens.” God created the great sea monsters and every living creature that moves… (Gen 1:20-21 NASU) God, therefore, is definitively the author of life. Question 2: Who is the Author of Death? The answer to this question took more study. It seemed logical that the devil would be the author of death. But God, in the book of Genesis, told us otherwise. The Lord God commanded the man, saying, “From any tree of the garden you may eat freely; but from the tree of the knowledge of good and evil you shall not eat, for in the day that you eat from it you will surely die.” (Gen 2:16-17 NASU, emphasis added) By the sweat of your face You will eat bread, Till you return to the ground, Because from it you were taken; For you are dust, And to dust you shall return. 2 (Gen 3:19 NASU, emphasis added) The first mention of death was made by God in the Bible. It was His idea. When Adam and Eve ate of the fruit, God decreed death. Death is a prescription and a curse. Death (or, put another way, an end to this earthly life) is God’s decree. 55 Ritchie Nov 2017. Christian Journal for Global Health 4(3):53-59 We realized that we had been thinking of ourselves, as doctors, as the enemies of death. Perhaps we had been thinking of Paul’s words in 1st Corinthians, “The last enemy that will be abolished is death.” (1 Cor 15:26 NASU) But on further study, this verse did not really apply to our current situation. It was a description of the end of Christ’s millennial reign on earth. It referred to the end of God’s prescription/ curse/decree, because all had been judged and set right. Perhaps the death referred to in this verse was the second death described in the book of Revelation. We realized that we were still under God’s prescription/curse/decree of death. So if we thought of ourselves as the enemies of death, we were setting ourselves up as the opponents of the Lord God of Heaven and Earth. It was singularly unwise to try to be God’s opponent, especially when we had promised to serve Him. One might ask, “Didn’t Jesus heal and resurrect? Don’t those actions identify death as the enemy?” It is true that Jesus did heal and resurrect! But we would be wise to remember what happened to every person whom Jesus healed and resurrected. Ultimately, they died. Jesus showed that He was compassionate and had power over life and death. But God’s decree was fulfilled in the end. So, for a Christian, earthly death, the first death, is not our enemy. It is not a failure, not a lost battle in which the Devil won, not the catastrophe that non-believing eyes might perceive. The end of earthly life is guaranteed, decreed by God. The Timing of Death But this raised the question of timing. What about an untimely death? What about the death of a child or the unexpected death of a person in his/her prime? After all, we generally acknow- ledge that a very elderly person with advanced Alzheimer’s disease might “appropriately” die. But what about a young person full of life? From the medical perspective, we might ask the question this way: Question 3: When My Patient Suffers an Unexpected Death, Who is Accountable—God or Me? In Western medicine, we are steeped in responsibility for our patients and have built a culture of blame for “untoward outcomes”. So, it was no surprise at all when our ob/gyn colleague felt great guilt when four of her patients died. But isn’t God sovereign? Which is it? Is God sovereign or are the actions of our free will responsible for the unexpected deaths of our patients? We returned to the Scriptures and the answer was both clear and mysterious. Somehow God is sovereign, and we have free will for which we are accountable. God is Sovereign See now that I, I am He, and there is no god besides Me; It is I who put to death and give life. I have wounded and it is I who heal, and there is no one who can deliver from My hand.” (Deut 32:39 NASU, emphasis added) In Him also we have obtained an inheritance, having been predestined according to His purpose who works all things after the counsel of His will.” (Eph 1:10-12 NASU, emphasis added) We Have Free Will I call heaven and earth to witness against you today, that I have set before you life and death, the blessing and the curse. So choose life in order that you may live, you and your descendants. (Deut 30:19 NASU, emphasis added) The Spirit and the bride say, “Come.” And let the one who hears say, “Come.” And let the one who is thirsty come; let the one who wishes take the water of life without cost. (Rev 22:17 NASU, emphasis added) We could not find verses that specifically spoke of a doctor’s responsibility toward his or her patients, but we did find many examples of verses in which a person was accountable (positively and 56 Ritchie Nov 2017. Christian Journal for Global Health 4(3):53-59 negatively) for his or her actions that affected another person. 3 Therefore, somehow God is sovereign, and we have free will. Somehow, God is sovereign over the lives and deaths of people, and somehow we doctors have a responsibility for the way in which our actions change the lives of our patients. This seems to be contradictory, but is better understood as a mystery. We cannot understand it, but God’s Word clearly conveys both situations as true. Looking at it from another point of view, God gives our patients life. But their parents have an important responsibility in starting that life, too. God gives our patients an end to their earthly lives. But they also share responsibility in the end regarding the choices they made in life (diet, exercise, smoking, driving habits, risks, etc.), and we, as their doctors, are responsible, too. God’s sovereignty and our free will are both fully engaged—a mystery, but a truth. In Western medicine, we place the burden of life and death on ourselves as doctors; but that gives no room for God’s sovereignty and is a flawed mindset for a Christian doctor. Further- more, placing the full burden on ourselves suggests that we are ultimately capable of saving every patient’s life. Such a mindset is not just unrealistic; it is frankly delusional. Though we as doctors do not bear the entire burden for the death of our patients, we must not become fatalistic. We should attempt resuscitation in appropriate patients. One day, during rounds, we witnessed a cardiac arrest in one of our patients. We successfully defibrillated and resuscitated him. Later, when he awakened, we told him that he had died, but that God had given him a few more days. We asked him whether he needed to reconcile with God or with anyone else. He was very glad for the opportunity to do both. Both situations are true: God is sovereign AND we have a role in our patients’ lives. Our actions matter. We must act with compassion and competence. Question 4: Do We Respect the Cultural Taboo Which Shuns Speaking About Expected Death? When we introduced the idea of advance directives to our charge nurse, she recoiled. She contended that speaking about death would violate cultural norms and might even cause the families to think that we were promoting death or bringing it about. We were stymied. We wanted to be culturally respectful to those in our care. But we realized that death is taboo in virtually every culture.4–8 It is always a difficult subject. In the US, we tend to avoid conversations about death. It is the same everywhere. So we are not dealing with a specific cultural taboo, but a general human condition. We do not like to talk about death. Though death is uncomfortable to discuss, the necessity of addressing it has become more widely accepted and even encouraged in Kenyan society. 8–12 Surveys have suggested that Kenyans want to know if their lives will end soon and want their families to be involved in the discussion.13 Patients of many cultures consider spirituality to be important by the end of their lives,4,5,14–16 and palliative-care patients who consider themselves to be more spiritually-oriented also tend to report less spiritual pain, depression, and anxiety.17, 18 Therefore, we should overcome our perceived awkwardness in approaching the subject of death and provide the spiritual balm our patients need. Furthermore, the Bible teaches us not to fear earthly death. As mentioned before, Paul saw earthly death as something to be anticipated. He saw death as a means “to depart and be with Christ,” which is “very much better.” (Phil 1:23 NASU) We, as Christians, should have no fear of death. If we do treat death as a fearful event, we are not thinking like Christians; we are thinking like pagans. If we avoid speaking of death, we are tacitly honoring a pagan understanding of death and failing to teach one of the chief joys of Christian life. Paul reveals this to us. But we do not want you to be uninformed, brethren, about those who are asleep, so that you will not grieve as do the rest who have no hope. For if we believe that Jesus 57 Ritchie Nov 2017. Christian Journal for Global Health 4(3):53-59 died and rose again, even so God will bring with Him those who have fallen asleep in Jesus. (1 Thes 4:13-15 NASU) Speaking with patients about their up- coming death also gives them an opportunity to reconcile with God, reconcile with important people in their lives, prepare financially, and plan for the ceremony. Rob Moll records the thoughts of gerontologist John Dunlop: You ask anybody how they want to die today and they say “Make it quick,” he says. Instead of fearing the slow decline, Dunlop, who has cared for hundreds of elderly patients, says, “I hope I die slowly.” A slow death offers opportunities to spend time with family, say good-bye and slowly orient a person toward life with God, he says. “I think most people who have thought it through will say there are more advantages to my family with my dying slow. It’s kind of selfish to want to die fast.”19 If we hide the news of upcoming death from our patients and their families, we deprive them of these opportunities for reconciliation and plan- ning. And, of course, we as Christian doctors must ensure that our patients have had the opportunity to respond to the Gospel. People who are aware of their own impending death are often far more sensitive to spiritual issues. We simply must help them to understand their situation spiritually. To do otherwise should be anathema to a Christian doctor. But when we are able to inform our terminal patients about their impending death, and help them and their families understand their heavenly future and the futility of highly invasive medical intervention, they are often quite amenable to considering the concept of a peaceful death. Our Chaplains helped us to understand that news of impending death should not be delivered abruptly, even if the news is delivered in a compassionate way. The news may be best brought through another family member and brought gradually. In addition, we found that most patients and families were not ready to think about choosing to limit heroic lifesaving medical efforts immediately after receiving the news of impending death, but were often ready after a day or two. Question 5: How Should We Encounter the Actual Event of Death? Not so long ago in our hospital, before we began using the defibrillator and “running a code,” the usual medical response for a dying patient was to pull the curtain and perhaps try a few interventions without much expectation of success. Then, when the patient truly died, the body was quietly moved to a side hallway behind another curtain, awaiting movement to the morgue. Families were not invited to attend the body in the ward, but only in the morgue. The entire “ceremony” was imbued with a sense of failure, embarrassment, and loss. I could not help but contrast this ceremony of death with the Ramp Ceremony which was held for the repatriation of soldiers who fell in Afghanistan.20 The ceremony usually occurred very early in the morning, often 2 a.m., when there were absolutely no distractions. The aircraft that would carry the body was parked front-and-center of the flight line. Hundreds of troops would come to the ceremony and would stand at attention in disciplined lines, honoring their fallen comrade. The soldier’s body, carefully prepared in a flag- draped casket, was carried with full honors into the aircraft for the journey home. It was a profound time—a time of loss, certainly, but also of great honor. Why couldn’t we have a Ramp Ceremony for our patients at our mission hospital? Would not such a ceremony be appropriate for a Christian hospital? If we were to institute a Ramp Ceremony, when the nurses were to notice that the patient was nearing the end, they would notify the team. The doctor would come. The other nurses would come. The family (if present) would come. The Chaplain would come. The other patients would even be invited to attend if interested and able. Any symptoms that appeared to distress the visiting patients would be attended to by the team. The team would pray, sing, and honor their brother or sister into the Kingdom. Wouldn’t that be a more 58 Ritchie Nov 2017. Christian Journal for Global Health 4(3):53-59 faithful response to the end of the earthly life and beginning of heavenly life of a believer? In consultation with our nurses and chap- lains, we began to approach some patients’ families with the idea. This ceremony was a new idea for most families, and we proposed it carefully, inviting acceptance. The explanation of this ceremony provided a wonderful opportunity to present the Good News to all who could hear. Some families did not accept the idea and asked for medical resuscitation. We followed their wishes. But some families did accept the idea of foregoing medical futility and celebrating the transition of life. When we have had the opportunity to use this ceremony, the entire mood around the deathbed had changed. Of course, there was mourning for the person who would be missed until reunion. But there was also celebration and honor. We realized that this ceremony need not be restricted to expected deaths; it could also take place after an unsuccessful resuscitation effort. Also, sometimes the timing was awkward. Sometimes the team was called because the patient was at the point of death, but death was slow in coming. We learned to talk about this beforehand. If the honoring team needed to disband and reassemble later, that was no problem. More worship and honor were better. The situation was also uncomfortable when the patient was known not to be a believer, and we, therefore, could not be confident of a joyful spiritual outcome. But we were determined to show kindness to all our patients and their families, and, of course, we purposed to share the Gospel with all. When the patient was known to be a believer, the ceremony of life transition could be joyful. The ceremony also provided an answer to the problem of “doing nothing.” When we had originally proposed withholding “heroic measures” for patients with terminal illnesses, our charge nurse objected. She said that it would be inappropriate to “do everything” for some patients and “do nothing” for others. But a ceremony of life transition was hardly “doing nothing.” Instead, it was a far more fitting and faith-filled way to honor a life. Patients’ families were glad for a way to honor God and His sovereignty at the same time that we honored their loved ones. Conclusion “Precious in the sight of the Lord is the death of His godly ones.” (Ps 116:15 NASU) Death, the end of this earthly life and transition to eternal life, is one of the most important events in any life. If God considers death to be precious, it is appropriate that we do likewise. Of course, when a medical resuscitation seems appropriate, we should attempt it. 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I had the profound privilege of serving with the US Marine Corps and UK Royal Army at Bastion Hospital in Afghanistan during the "Surge" in 2009- 2010. Peer reviewed Competing Interests: None declared. Correspondence: Dr James V Ritchie, Kabarak University, Kenya. ritchiejim263@gmail.com Cite this article as: Ritchie JV. Death in a mission hospital. Christian Journal for Global Health. Nov 2017; 4(3): 53-59. https://doi.org/10.15566/cjgh.v4i3.189 © Ritchie JV. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. 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