Podcast: A Trauma Surgeon’s Guide to Modern Medicine and the End of Life (Kathryn Butler, MD)
This article is part of the The Crossway Podcast series.
Biblical Wisdom for Medical Care
In this episode, Kathryn Butler, a medical doctor and the author of Between Life and Death: A Gospel-Centered Guide to End-of-Life Medical Care, shares from her experiences working as a trauma surgeon in an ICU, responds to common misconceptions about CPR, ventilators, and other forms of intensive care medicine, and offers biblical wisdom for walking alongside loved ones at the end of life.
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Between Life and Death
Kathryn Butler, MD
This book aims to equip Christians facing end-of-life decisions by simplifying confusing jargon and exploring biblical principles families need in order to navigate the transition from this life to the next.
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Full Transcript
Welcome
Matt Tully
Kathryn, thank you for joining us on The Crossway Podcast.
Kathryn Butler
Thanks so much for having me, Matt. It’s really good to be here.
What Is the ICU?
Matt Tully
You’ve spent about ten years working in an ICU and part of that time you were a trauma surgeon working on that team. What exactly happens in an ICU and how does that relate to other sections of a hospital, such as the ER?
Kathryn Butler
An emergency room (ER) is where you come initially to receive treatment acutely. Patients who come into the ER will range from people who—I’m not kidding—have a rash, something very benign, up to people who are deathly ill. The ER is the place where we initially stabilize patients, and then we transfer them to other wards throughout the hospital to receive treatment.
The Intensive Care Unit (ICU) is where the sickest patients in the hospital go. It’s where we can provide one-to-one nursing, it’s where we can use technology that is sufficiently sophisticated, to the point that you need to have a nurse with you monitoring it at all times. In the ICU nurses will check on patients every hour and take vital signs, versus every four to six hours in the other areas of the hospital. In the ICU it’s around the clock. And it gives us the capacity to provide the most intensive care possible.
In my own practice I was a surgical intensivist. The people that I would care for would be either people who had finished some kind of operation that was very, very serious and had the potential for complications afterwards that were severe and they needed to be monitored; or, it was people who had complications from something that was surgical. That could run the gamut from an operation that developed a life-threatening infection, to patients who had a heart attack after a surgery, orc patients who come in after trauma, such as motor vehicle accidents, where they’re dealing with multiple-organ damage. So the ICU is the sickest patients in the hospital. We have wonderful success stories from that avenue from patients who were deathly ill who we were able to usher back to health, but it’s also a place of great sadness because with how aggressive we tend to be in our treatment of people, beyond the even point where we should. Honestly, we have situations where people are on multiple tiers of supports—ventilators, continuous dialysis, medications to keep the blood pressure up and the heart going, very aggressive interventions—at the end of life, which creates a very murky and upsetting situation for a lot of patients and their families.
Training in the ICU
Matt Tully
That’s so hard. I think most of us probably can’t even imagine what that kind of context is like and the pressures you must feel as a physician in there. What was it like when you first started to work in the ICU? I assume as you were training . . . describe what that experience was like.
Kathryn Butler
I was intimidated at first, which is partly why I then developed a love for it. I was intimidated because there were so many things that you had to pay attention to. You’re used to thinking about healthcare as maybe a handful of problems per patient, but in intensive care things are so complex that you literally have to go by systems. So everyday when you’re thinking about a patient’s plan you think about what’s going on neurologically, and then what’s going on cardiovascularly, and you just go down the list of every single organ system. As a medical student that was very intimidating, so I threw myself into study of it because I wanted to be able to help these patients as best I could. And then I fell in love with it because I just realized what a gift it was to help people through some harrowing situations.
My book talks mostly about the downsides of this technology, but there are plenty of success stories too, and maybe that’s fodder for another book about how we should be thankful to the Lord for what he’s given us with medicine. It’s difficult and emotionally trying, yes; but the opportunity to partner with patients and their families at their most vulnerable and to help usher them through is priceless. And then later in my practice, after I found Christ, to pray for them and sometimes with them was just a privilege. I loved the work.
Matt Tully
That is again one of those contexts that few of us I think can imagine. And you write, echoing what you just said, you write that, “ICUs tend to blur the boundary between the heroic and the inhumane.” What do you mean by that?
Kathryn Butler
Oh, goodness. It’s an insidious process. When we think about this technology, I find that people will often take a very black-and-white approach. They’ll say, “I want everything done under all circumstances.” “Everything” meaning chest compressions, CPR, ventilators, everything. Or they will say, “I don’t want anything done. God will take me when he’s ready to take me.” And those kinds of decisions, unfortunately, are too concrete for what actually happens. This technology can be life-saving and life-affirming when it’s used in situations where we can reverse what’s making someone so sick. On the other hand, if what is making someone sick and debilitated is a chronic, terminal illness that is worsening, the technology we use can actually only prolong someone’s death.
To give you an example: if someone comes in and they’re otherwise healthy but they’ve got a severe, raging pneumonia, a ventilator in that circumstance will potentially be life-saving because you put them on the ventilator to support their breathing, you give them antibiotics for treatment of a condition that’s curable, and it’s anticipated that they’ll recover and go home. If someone comes in with respiratory failure, but it’s from disseminated cancer, and emphysema, and multiple other issues at play, that ventilator might not actually save their life because what is underlying that respiratory failure is something that’s not curable. And in those kinds of situations we can give all of these interventions that are very aggressive—and they’re worth it if you can help someone to recover and go home—but if that’s not possible, we steal away time that they could be spending with their loved ones, and we cause incredible discomfort. It’s very uncomfortable to be on a ventilator. You have to have a tube down your vocal chords. That’s very irritating, so you have to be sedated, so you can’t communicate with anyone. People have described to me that it feels like they’re suffocating and they’ll say, “I never want to have that again.”
These interventions do cause suffering. And so knowing that there’s that potential, we need to be good stewards of this technology and ensure that we’re using it to help and we’re not inflicting further suffering with it.
The Realities of CPR
Matt Tully
Speak about CPR, too. I think we all have a perception of what that looks like from TV and movies, but we probably all understand to some extent that that’s not necessarily true to life.
Kathryn Butler
That’s not how it looks! No!
Matt Tully
What are some of the common misconceptions that you’ve found that people have about CPR?
Kathryn Butler
The whole idea of CPR what it does is it essentially buys you time. It stands for cardiopulmonary resuscitation and basically you’re compressing the heart between the chest, sternum, and the spine to try to pump blood to the head so that you can profuse the brain and try to deliver oxygen to it. So it’s meant to try to continue to give oxygen to the brain while everybody in the team taking care of you tries to figure out what’s going on and to reverse whatever caused you to have a cardiac arrest in the first place. So it’s something to help while they figure out what’s going on. It’s not something that when they do it you’ll come back to life. And there are downsides to it.
The sitcoms and the shows usually portray people running in with paddles and they give a shock and the patient sits up and everything is good. Right? That is very rarely the case. There are a handful of cases when someone who receives CPR will immediately recuperate. That’s usually if it’s a specific type of arrhythmia—meaning that the rhythm of the heart, the way the heart is beating in its synchronizing of it’s chambers—that you can reverse right away. I’ve had one patient who sat up and was just confused.
But for the vast majority of people who are sick enough to need CPR, there are a lot of negative things that you need to consider. If you have someone who is healthy and has few medical issues that are chronic, CPR makes sense. But the survival rate after CPR is actually quite low. And additionally, to do CPR properly, you break ribs. I remember the very first time I did it as a medical student I felt absolutely sick to my stomach and felt like I had assaulted this poor elderly woman whom I’d never met before. But they called a code and I ran into the room with everybody else and I started doing compressions and I felt that crack beneath my palms and I thought I was going to pass out. I felt like I was committing assault on her. And that’s what you have to do and it’s worth it if you can bring a patient back, if you can save someone, if what they have is reversible. If someone is already dealing with disseminated cancer, or end-stage heart failure, chronic heart failure, or some kind of debilitating disease that’s long term, that’s not curable, and then has an event like this, the chances that you’re actually going to restore them back to their original health are very low because though you’re performing CPR, it is not perfect. The brain is not getting enough oxygen as it would need and the longer that time passes the patient actually suffers brain injury.
So the chances that someone is going to recuperate from CPR if they’re horribly sick and debilitated to begin with is actually pretty low, and these kinds of conversations really need to be had carefully with a physician who knows you well so that he or she can shepherd you toward the right decision. The majority of television shows will show that someone has an arrest and they receive CPR and next thing you see is that they’re going home the next day. But there were a couple of studies done looking at the rate of recovery from CPR as portrayed on TV, and I can’t recall the actual statistic I wrote in my book but it was something ridiculous like 80%, when the reality is more like 10% actually recuperates after CPR. And it depends upon the medical background and what we’re talking about here, but overall it’s about 10%.
Matt Tully
So it’s not as foolproof as we often seem to think it is?
Kathryn Butler
No, it’s not. It is necessary if someone has a cardiac arrest—and when I say cardiac arrest what I mean is any kind of condition that prevents blood flowing from the heart throughout the body. So it could be that the heart stops, it could be that there’s a massive clot that’s blocking blood flow in the arteries leaving the heart, there are a whole host of things that can cause it. And the cause determines whether or not you recover after you have CPR. So that’s another way that we are misled and our understanding of things can be so far removed from the truth. It’s because what we know is from the media and it really doesn’t align very closely with reality.
Disconnect Between Medicine and Spiritual Questions
Matt Tully
In your book you reflect on the disconnect that you sometimes felt trying to explain all the technical details and the medical terms to patients and their families while at the same time feeling like a lot of the questions that they had—the deeper questions, the spiritual questions that they had—related to the end of life were things that you just couldn’t answer or weren’t being answered for them. Can you elaborate on that disconnect that you felt?
Kathryn Butler
Oh, absolutely. I came to Christ during my training. For the first half of my experience in medicine I wasn’t really even cognizant or aware of what people were struggling with. And I went into ICU care because, honestly, I thought it was the most fantastic way to help people. These people are in the throes of some of the most traumatic instances of their lives and they’re scared and they’re terribly sick and the technology we have really is a blessing because in many circumstances it does allow us to return people home to their families. But there is also a dark side to it. Oftentimes the treatments or the support we can offer doesn’t actually cure patients, it only prolongs death. It can be very painful, it can deprive them of a voice during those last moments when they should be focusing on the whole trajectory of their lives and thinking about their relationship with God and with their families—kind of the old idea of putting your life in order at the end. We’ve deprived people of that in the setting of the ICU because the technology is sophisticated, but in not all instances is it curative.
I would find I’d have these meetings with families on a weekly basis, several times a week sometimes, where they were trying to vouch for loved ones and make heart-wrenching decisions that were just so anguishing because they were grieving over the potential loss of a loved one and then strapped with these What do I do? scenarios. And you know, I think that is appropriate, we all do that when we’re in a dilemma. So they would turn to their faith, which is absolutely what I think we should do; but the landscape that they’re dealing with, with all the technology and the foreignness of it and the vocabulary that they don’t understand, makes it so hard without help to try to navigate these things in a faithful, God-centered way. And people were just struggling. They would cling to one idea from the Bible, but in a very concrete, black-and-white fashion and ignore other ideas and it would just add another layer of agony to what was already such a difficult and trying process. My heart just broke for these families that I was trying to help through these terrible situations.
Matt Tully
So are you kind of saying that all of the medical technology and insights that we have that were kind of designed to help prolong life could sometimes actually get in the way and make it harder for patients and families to actually think about what’s happening?
Kathryn Butler
When you think about the history of the dying process in America, people used to always die at home. It was a profoundly spiritual experience that families witnessed and it was supported by your clergy and within a community. In the medicalization of the dying process, we’ve completely removed that awareness from lay people. And you can see it in the statistics: about 86% of people a century ago died at home. Current surveys show that’s actually what people still want. Seventy percent of people in America, according to recent surveys, have said they want to be at home in the place that they love, with the people they love and what has been dear to them in life when they pass away. But only 25% of us actually do. The majority are in ICUs and it’s become so sophisticated and so complicated that a terrified loved one will come to a family member’s beside and they can’t tell whether or not somebody who’s on a ventilator, and receiving medications, and is on dialysis is recovering or is on the brink of dying. That’s something that the physician needs to help them navigate to help explain what the numbers mean, to explain the disease process. And it’s really hard for a family member who’s part of the laity to decipher that difference between recovery and decline. You can’t tell from the doorway.
So families are left to rely upon their physicians, and the problem is that our medical system is a secular system. There have actually been studies out of Harvard looking at the responses that physicians have to terminally ill patients when they voice spiritual concerns, and the vast majority of physicians drop the question, and don’t follow through on it, and don’t even necessarily refer to chaplaincy because they’re that uncomfortable dealing with it. So people wind up in these situations where they’re overwhelmed, don’t know what to do, and then they’re spiritually stranded and it’s very, very difficult.
Matt Tully
Why do you think it is that doctors have such a hard time broaching those topics?
Kathryn Butler
That’s a great question. I’m actually reading an incredible book right now called Hostility to Hospitality that looks at this. It’s written by a husband-and-wife team, Michael and Tracy Balboni, and they actually did outcomes research showing this divide in spirituality and medicine. And it’s multifaceted. I think we’re so used to thinking of healing as a blessing and something that mirrors our faith because we’re laying on hands, we’re caring for one another, we’re showing mercy. Those are all beautiful things that point to God. But the history of modern Western medicine, the bioethics on which we lay our groundwork for how we practice medicine, is secular. It comes out of the Enlightenment. And so the roots of medicine are far removed from Christianity. The other thing is that because there’s so much emphasis on science within medicine, because there’s so much emphasis now on technology and cure, there is just not much of a culture of considering spirituality. It’s just as in modern day secular circles will assume that there’s a divide between science and religion—that you can’t have faith and also consider science—that there’s this divide between the two. That mentality permeates medicine and so you’ll have physicians who are very deeply compassionate but who feel very uncomfortable touching upon any spiritual concerns that patients might have. It’s part of the training; it’s part of the whole culture.
When There’s Disagreement over End-of-Life Care
Matt Tully
And in addition to that it seems like while there might be a lack of conversation about some of these spiritual things between patient and doctor, there’s also, as you note in your book, sometimes a lot of confusion and disagreement between loved ones, and doctors, and patients. Speak to that a little bit.
Kathryn Butler
You mean specifically in terms of loved ones not agreeing among themselves what should be done?
Matt Tully
Yeah, not agreeing and not knowing what’s the path forward and how to make decisions on behalf of a patient.
Kathryn Butler
This becomes so hard because we tend to lay on our own opinions or what we want. When you have someone who’s dying that you’re grieving for, the last thing you want to say is, “Okay. Let’s withdraw these treatments.” You want to keep pressing on. And those kinds of background, the messiness that follows us through our lives and our relationships can infiltrate these kinds of decisions. What we really should be aiming to do for a loved one who’s nearing the end of life is trying to be his or her voice when they can no longer speak. And that happens very frequently in ICU care. When they’ve done research looking at people at the end of life the majority cannot make decisions for themselves. Either because they’re on a ventilator and they can’t speak, or very frequently because the illness themselves disable them to the point where they are very confused or they can’t talk. So the role then, the burden, then comes on the loved ones to be that person’s voice and to vouch for what he or she would say and would want if he or she still had the capacity to speak. But you know there’s so much that’s involved in terms of family members who might not have had a good relationship with the loved one in question who now are feeling guilty. Others who have a misunderstanding of what it means to continue on with aggressive care or to set limitations. There’s a tremendous amount of confusion that can arise in these situations that are already so emotionally charged.
Advance Directives
Matt Tully
Whether it’s CPR or a ventilator like we talked about, you mentioned the need for discussing these things with our doctors and with our family beforehand and that kind of gets into the territory of the importance of advance directives and other things like that. What is an advance directive and why is it important?
Kathryn Butler
An advance directive is a document that is meant to record your wishes for aggressive, life-sustaining treatment. And it’s kind of an umbrella term. There are orders—people who have been around hospitals will hear people talk about DNR/DNI orders—which basically allows you to say via a checkbox format, “ I want CPR or I don’t want CPR, I want a ventilator or I don’t want a ventilator*. The thing that I think is more important for people to consider if you’re going to consider one of these documents, which I recommend you do, is a living will because it actually allows you to write a narrative of what your values are and what you would accept under what circumstances. But the whole idea of filling out an advance directive is vitally important because as I mentioned earlier the majority of us at the end of life will not be able to voice our wishes. The sad thing is that most of us do not want to consider these forms or fill them out because we’re like, “Well I don’t know what I would choose. I’ll just decide when it happens.” And most of us unfortunately can’t. And it has significant ramifications on those that are then left to make decisions for us if we leave them in the dark. Family members of loved ones who pass away in the ICU have significant rates of depression afterwards. They suffer from complicated grief. Many of them even meet criteria for Post-Traumatic Stress Disorder.
So when we don’t think about these things ahead of time, there are ramifications not only for us in terms of our spiritual walk as we consider What is acceptable? What is not? What do I need to continue to serve God to the end of my days? But also it potentially hurts those we love because we strap them with making decisions for us that is just an impossible burden without guidance.
Advice to Pastors
Matt Tully
That’s really helpful. We have a lot of pastors who listen to the podcast and what advice would you give to them? They are ones who are often walking alongside their people at the end of life and they’re getting lots of questions especially if doctors and family members don’t always know how to navigate these waters I think many people look to pastors to help them. What advice would you give to a pastor listening?
Kathryn Butler
One thing and this is just based upon my experience of how I’ve seen loved ones and patients respond. First of all I would recommend the pastor should also feel at liberty to talk to physicians caring for those in their congregation as long as they’re given permission. If that will help. Because sometimes these things are so murky that it helps to have an understanding of one key thing which is, when we’re having these discussions are we talking about measures that promise to prolong life, or to prolong death? And that is a hard distinction to make when you’re not familiar with what is going on medically with an individual. And what I mean by that is would a ventilator in a certain situation be curative? Or would it be something that would only prolong the dying process and be a futile treatment? People often are just so overwhelmed they will cling to one particular principle or another from Scripture to the exclusion of all others and feel like oftentimes that they don’t want their loved one to suffer, but they don’t know if they can refuse treatment if that’s acceptable if that’s biblical or not. They’re often seeking guidance from someone who knows the Lord and can help them interpret these things to say, “This is okay.” Or, “You need to press on.”
So first of all I think pastors should feel empowered to ask if they have questions medically that would help them understand that. Even if it’s just that: would these things preserve life or would they prolong death? And I think also then understanding that a lot of family members, as I mentioned, are often clinging to one principle. We Christians have a track record that has been documented in the medical literature of pursuing aggressive treatment beyond the point of hope and I think very often it’s because we cling to the idea that life is sacred and so we need to do everything possible to keep someone alive. And that is true that our lives are a gift from God and we’re to be stewards of it, and we are to protect it, and our time is in his hands. However, that doesn’t mandate—and the Bible nowhere mandates—chasing after aggressive interventions that will guarantee undue suffering and prolong death but don’t offer hope for cure. And I think very often people suffering don’t grasp that unless it’s pointed out to them. And they feel very tremendously guilty about any idea of declining treatment because they feel like they can’t. Without realizing that death comes to all of us, and when we very stalwartly cling to this idea that we have to pursue every treatment at all costs, in a way we’re actually denying God’s sovereignty. And we’re not trusting in him that he is sovereign over our lives and our death, and that our hope is in someone who is much greater than the ICU room and the ventilators but who has conquered death. And so even when we have to face it and even when it will come because it will come, we have our hope in Christ. And I think those are the kinds of things that I feel loved ones need to be shepharded toward to understand that it’s not necessarily God-honoring to chase after futile treatments, and that we’re meant to be merciful and loving to those around us, and also that God is in control, and that we have a hope that so far surpasses any of the technology that we can agonize over in these moments.
Closing
Matt Tully
That is so true and it is so important that we keep all of that in mind. Those more firm realities that we can pin our hope on in the midst of this pain and tragedy. Kathryn, thank you so much for speaking with us today and for sharing from your experiences as a physician and your experiences walking people to the end of life.
Kathryn Butler
It’s my pleasure. Thank you so much for having me on for this.
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