The end of life is not normally a subject we talk about that much, but it’s rare that we have someone who can approach it with the insight and sensitivity of our guest—Dr. Katie Butler. She approaches and clarifies many issues around the end of life from the perspective of a biblically centered physician who has specialized in critical care surgery in her practice. Join us for this helpful and practical discussion about something that we all will face.

More About Our Guest

Portrait of Kathryn Butler

Dr. Katie Butler is a trauma and critical care surgeon, who trained at Columbia and practiced for many years at Harvard. She is now home schooling her kids and writes for Desiring God, the Gospel Coalition and her own blog at Oceans Rise.

Episode Transcript

Scott Rae: Welcome to the podcast “Think Biblically: Conversations on Faith & Culture.” I'm your host, Scott Rae, dean of faculty and professor of Christian ethics at Talbot School of Theology, here at Biola University.

Sean McDowell: And I'm your cohost, Sean McDowell, professor of Christian apologetics at Talbot School of Theology, Biola University.

Scott Rae: We're here today with Dr. Katie Butler, who's authored a terrific new book entitled Between Life and Death: A Gospel-Centered Guide to End-of-Life Medical Care. Katie's a former trauma surgeon, a former faculty member at Harvard Medical School. She's taken a break from clinical practice to homeschool her children at present, but Katie, I'm so delighted that you found the time to put a lot of the experience that you gained in your years as a trauma surgeon, put them down on paper for the average person to read. The book is so insightful and so helpful.  Just very grateful to you for taking the energy that it took, I know, to put this together.

Kathryn Butler: Oh Scott, thank you so much. That's a lot coming from you given your background with working on ethics committees before. I just pray that it helps people through some, what are really some harrowing situations. 

Scott Rae: Let me start with this. You've seen a lot in your years as a trauma surgeon, ER doctor. I mean you've spent a lot of time with a lot of patients and a lot of families and have seen a lot of natural death and a lot of unnatural death, too. 

Kathryn Butler: Yes.

Scott Rae: You talk in the book that the end-of-life experience for patients and families has changed like light-years in the last 50 to 75 years. How, could you just sort of briefly summarize how that, how the end-of-life experience has changed for patients and families say in the last century?

Kathryn Butler: Yeah, of course. If you look back over the centuries, death, really, the practicalities of death mirrored its spiritual realities, meaning that death happens at home with family in the environment and surrounded by the relics of our lives that helped build who we are. And it was something that was part of the community. Pastors would be involved. So it really was something that mirrored its spiritual importance. And if you look at statistics and poll Americans, year after year, we find that 75–80% of us still uphold this idea of death as a spiritual event. And we all say that we want to die at home. However, we have seen a dramatic shift whereby the reality is that very few of us do.

The data most recently says that anywhere from 25–40% of people actually die at home, while most of us actually spend our last days in institutions, in acute care hospitals or rehabilitation centers or ICUs. And what this discrepancy has done is that we don't have any concept of what actually happens in death because it's become so highly medicalized and we don't talk about its realities that when we're then confronted with it, it can pitch us into some horrible dilemmas where we are on machines and are not able to speak, given our illness or given the interventions that are imposed on us. And then when we are unable to vouch for ourselves, our loved ones are stressed into the position of having to make decisions on our behalf. And very often, they are very ill-equipped to do so. And studies have shown that the impact upon them is very real. They suffer anguish not only over the impending loss of a loved one, but then can have anxiety and depression and complicated grief and even post-traumatic stress disorder afterwards just from the agony of having to make decisions about life and death for someone they love without any clear guidance in such an unfamiliar environment.

Scott Rae: Well one of the things I so appreciated about what you've written here is this, I view your book as just a major reality check on what patients and families actually go through at the end of life. In fact, for example, you call the ICU a hotbed of suffering.

Kathryn Butler: Yeah.

Scott Rae: And you mention that stays in the ICU, both for patients and families, produce some of the same symptoms that post-traumatic stress disorder does, similar to what soldiers suffer from. 

Kathryn Butler: Yeah.

Scott Rae: I think that's breaking news to most people who do not practice medicine or have regular contact with hospitals. Why don't doctors give more realism about what end-of-life aggressive treatment will do just in terms of the general overall suffering that it tends to inflict?

Kathryn Butler: I think there are a number of reasons. One of them is that we didn't have any idea the long-term effects of ICU care until fairly recently. Our outcomes and our survival rates in the ICU were pretty low until the last 20 years. And it's been, with the implementation of quality control measures like efforts to reduce hospital-acquired infections, protocols to try to help us better resuscitate patients with severe infections. These kinds of protocols have really helped to get people out of the ICU and prolong survival. And so it's really only been over the past 15 years or so that we started to acquire longer term data for patients who have been in the ICU. And it wasn't until 2010 that we actually coined a term — post-intensive care syndrome — because people after being in the ICU can suffer long-term psychiatric effects in addition to, if we use paralytics, medications that paralyze you when you're on a ventilator. They can actually suffer from long-term weakness and require long-term physical therapy or neuropathy, so they have chronic pain. And we just didn't know about this until the past 15 years or so. 

The other things that I would say is that medicine has become so highly sub-specialized that the ones who are really seeing the effects on people in the intensive care unit are the ones who are there ministering to them and caring for them moment to moment. The practice of medicine has become so highly compartmentalized that people that, most people are, the doctors that most people are interacting with on a regular basis in their offices or just to go for a cardiology consultation aren't seeing the realities of what’s actually happening in the ICU and how devastating it can be for people. 

And then I would say the third thing is that in general medicine has a culture of what Atul Gawande coins is a culture of cure. There's very little discussion about suffering and dying in medical training. And I can recall that the first time that I encountered death and had to declare someone deceased, I was a resident and no one had discussed with me as a medical student what to do. I didn't know what to expect because the focus is so heavily honed in on what's the next thing you can do. And so in terms of looking at the broader picture of when are we actually helping and when are we returning people home versus when are we inflicting suffering without benefit and potentially committing people to real trauma? Those things, it's just kind of outside of the mind frame of a lot of physicians. 

Sean McDowell: Do you think there's any other deeper reasons why, maybe in medical training, that, that's not talked about? Is it avoiding it? Is it kind of the deeper implications theologically that they'd rather not go there? Or is it really just like you said we're just so focused on saving and then kind of move on?

Kathryn Butler: Oh that's a really interesting question. I would say that's a, there's a wonderful book that I could recommend. I don't know if you've read it, call Hostility to Hospitality, by a husband and wife team, Tracy and Michael Balboni. He's a theologian. She's a radiation oncologist. And they actually look at the divide that’s  present right now in spirituality versus medicine. They did a study of four different Boston hospitals and they did a cross-sectional survey of 75 terminally ill cancer patients. And what they found was that 80% of the patients voice that spirituality and religion were important to their illness experience and their forecast of their end of life and that experience and that process. But the numbers of physicians who said that it was important to them or that they felt comfortable actually providing spiritual care was minuscule. And patients reported that only 1% of physicians offered chaplaincy in their care, which, to me, is just astonishing.

But there is a real clear divide in terms of spiritual mindedness among medical caregivers and patients that certainly is contributing in some effect. But I do, to your point Sean, in terms of denial, I think there is a big component of denial there as well where physicians, because of our training, we're taught to try to cure disease. It feels like failure to say that you can do no more. And there's not a general acceptance of death being something that's inevitable. It's something to fight against. And that trickles down into the experience that people have then at the end of life where we're not willing to say, "You know what? This is not going to help." And it really requires, I think, a mind shift which is coming around, I think. People are being more vocal in terms of Atul Gawande's book. And there was recently a memoir out by a Titus care specialist out in California saying that we really need to change the conversation when people are ailing and struggling with terminal illness to focus instead on what are their values and what do they really need most at the end of life when our cures run out.

Scott Rae: Katie, you make a, I think, a very helpful distinction in your book between treatments that cure and treatments that support a patient. And you distinguish between technology that preserves life and that which prolongs death. I found it particularly helpful that in the treatments that simply prolong death you make the point that they always increase suffering. In fact, I would probably make the case that they always, almost always involves a net increase in the level of suffering that a patient experiences.

Kathryn Butler: Mm-hmm (affirmative). 

Scott Rae: But as you know at the end of life that distinction between technology that preserves life and that which prolongs death can get a little, there's some gray in that and it becomes a little bit fuzzy. How do you help families decide which is which? Which things cure? Which support in helping them make treatment decisions?

Kathryn Butler: Right. I think the key thing to ask is whether or not the underlying illness, the underlying process that's threatening a loved one's life is reversible or can be improved or it can be recoverable. Sometimes think about ventilators and dialysis and all these things that we do in the intensive care unit, which is under the umbrella term of life support, we think about it as treatments. And it's not. We can put someone on a ventilator indefinitely. But what determines whether or not they're going to get better and go home and come off the ventilator depends on what is the underlying process driving the failure of their lungs? 

So to give you an example, if someone comes in with pneumonia with a bacteria that's very common, that's easily treated, and they're otherwise quite healthy and they require a ventilator, that ventilator's most likely to be temporary because we can reverse the underlying process with antibiotics. And they're expected to be on a ventilator a few days. They can come off it and they can return to their lives. 

It's a very different scenario when you have someone who comes in terminally ill with metastatic lung cancer and end-stage emphysema who comes in with a fungal pneumonia that's much harder to treat. That, in that scenario when they come in with failing lungs, that ventilator is most likely to be a permanent fixture and the underlying illness is likely not recoverable. 

So it requires talking with doctors about what is it that's driving the illness in this situation? And is it something that can be reversed or is it something that can be improved? And then the question comes, if it can be improved, what kind of life will it look like for the loved one afterwards? Because oftentimes, just as you say Scott, it's not so black and white of getting completely better or sliding into death as much as improvement with this new disability. And that really gets into questions of suffering for what would a loved one say if he or she could speak? And this is why these conversations are so critical to have before a life threatening event happen, to try to discern what would be too much suffering and what would somebody be willing to endure to achieve what's most important in life and to continue to walk with the Lord and what would just be unbearable. 

Scott Rae: That's particularly helpful because the way this is done in the bioethics literature is you talk about the futility of treatments, but most treatments are not futile because I mean if they were physiologically futile we just wouldn't prescribe them because they simply don't work. Futility doesn't really capture what we need to capture. It's about, is the disease reversible, or can it be improved but then at what cost? 

Kathryn Butler: Right, exactly.

Scott Rae: I think we've been very reluctant to ask that question, at what cost?

Kathryn Butler: Mm-hmm (affirmative).

Scott Rae: And that seems to me to be particularly important in this. How do you get families to consider the, you know, what they actually might be authorizing for medicine to do to their loved ones when they're not at the bedside? They don't experience any of this. They don't ... they authorize these treatments and then go to the waiting room or go out for lunch or go home. And maybe not come back for a few days.

Kathryn Butler: Yeah.

Scott Rae: So how do we help get, how do we help families see what exactly are the costs that they are imposing on their loved ones? I think in many cases, for their own individual benefit not so much for their loved one's benefit.

Kathryn Butler: Yeah, yeah, absolutely. And you know in terms of the individual benefit I think it's just so hard because the people whom we’re asking to make decisions are struggling with their own turmoil, meaning scared, worried to lose a loved one, grieving. There might be all sorts of emotional history there that we're not aware of and then we have to have them make these decisions. I think it really has to focus on what would the loved one say or do. And this is where I think it's so critical that we have these conversations ahead of time and try to formulate advanced directives. But the narrative should always be what would my loved one want. Not what I would want. Not what I would want for him or her. But as image bearers of God, part of loving those who are entrusted to our care is to say, "Okay, how can I be your voice when you can no longer speak?" 

And so as physicians the onus is on us to really explain what is the likely outcome. And sometimes we don't know. And sometimes it's appropriate to continue on with everything. But when it's very clear that someone's debilitated and has an end-stage disease, we as physicians need to pause and say, “Wait a minute. Is this the right thing to do or are we going to be inflicting needless suffering?” And we should always be having conversations with loved ones about what would your loved one want? Having had these conversations and if they haven't, to try to tease out what are their values? What is it that throughout the trajectory of their life they've pursued and at what cost? And what have they voiced as being unbearable in the past? 

Sean McDowell: You know Katie, speaking of individual's values, you cite statistics that seem to suggest religious people actually opt for more aggressive treatments at the end of life if they claim to believe in eternal life. How do you make sense of this seeming tension?

Kathryn Butler: Yeah, yeah, so there actually have been several studies looking at this, so it's been duplicated several times. The data actually looking to try to elicit from people their rationale is less robust. That has suggested that people who are, use religious coping to try to get through an illness will often be praying for a miracle and insisting I'm going to continue, I'm going to do everything because God's going to heal me. I can tell you from personal experience that what I see much more often have been Christians, is that there is a tendency to cleave very tightly to the principle that mortalizes sacred, but ignore the overall arc of the Bible in terms of what God teaches about who he is, who we are in relationship to him, and what he's done for us in Christ. Life absolutely is sacred and is a gift. And looking back to the Ten Commandments, it should be preserved. 

However, if we cling to that and ignore the fact that death also comes to everyone and that God has authority over our life and death and that as Christians, we have a hope that supersedes our death thanks to what Christ has done for us. It's almost as if that clinging to that principle becomes an idol. And I see that very frequently where people will misconstrue the fact that we protect the unborn and we are, that we oppose, appropriately, physician-assisted suicide as a misinterpretation that we then need to do everything at all costs.

Sean McDowell: So what would you say to a family who wants to cling to the possibility of the miraculous until the end and yet realize that oftentimes God doesn't perform miracles. Do you just live in that tension?

Kathryn Butler: First of all, I would say that those who are really clinging to that idea and are stalwart in saying that we need to do everything are usually those who are really hurting and are very scared. And so I've found that you have to proceed very delicately. And sometimes you might not have a frank discussion about it until you've developed a relationship with that family member because otherwise they will just shut down and think that you're fighting them and that's not the case. 

I think if you develop a rapport where they trust you and they realize that you really do want to care for their loved one as they care for them, and you've developed that trust, then talking about the fact that yes, God performs miracles, but by definition, a miracle is outside of science and he doesn't need our medical trappings to perform it. Jesus raised Lazarus with a command. He performed miraculous healings all throughout his ministry with soil and his own saliva. I mean there is, we don't require this kind of technology; he doesn't need our help to perform a miracle. 

And the other thing, I find that reflecting upon Jesus in the garden of Gethsemane is very helpful because here's one who has all the power of the Father at his disposal if he chooses, who is praying, “Lord, please take this cup from me. Don't ordain that I suffer.” But in this next breath says, "But not my will, but your will." And I think that's a very helpful mind frame. Pray for a miracle, yes. God does enable miracles. But we can't bend his will to ours. And even if we think that our loved one's miraculous healing is the only possible ultimate good, it may not be to God's glory. Or it may not be the ultimate good that he can see outside of space and time. And so pray yes, that ultimately we need to honor God's will. 

Scott Rae: You said that a lot better than I would say it to a family. I've often been tempted to say to families, if we want to hope for a miracle, then let's go for broke and turn off everything.

Sean McDowell: Wow.

Kathryn Butler: Yeah, yeah, yeah. 

Scott Rae: But your response is, I think, a bit more gracious than mine. Although I have been tempted to ask families, who I know are believing families, to say, “Do you really believe what you say you believe about resurrection and eternity?” 

Kathryn Butler: Yeah.

Scott Rae: Because from the way they're holding onto earthly life, and I get that. I think your point's right that they often do that because of the pain that they're feeling themselves.

Kathryn Butler: Exactly, yeah.

Scott Rae: We had a phrase in the hospital that we would, that we would sort of communicate with each other who were caring for different patients when, we would say, "We are now treating the family." 

Kathryn Butler: Mm-hmm (affirmative). Mm-hmm (affirmative). Yup.

Scott Rae: And we would, when we were imposing treatments for the family's benefit. I tried to get across to family members that, that's almost always unethical to impose burdens on a loved one, not for their benefit, but for the benefit of the family members who understandably have great difficulty letting go because their loved one is going to be in a different and better place. But we're not. 

Kathryn Butler: Right. Right.

Scott Rae: The ones who are left behind are not in a better place. 

Kathryn Butler: And there's often a lot turmoil that we just don't see in terms of guilt or whatever it is they feel like they're going to be giving up on their loved one and they can't do that. There's also a lot under the surface that's tangled in there. And it's not really just about what is the best thing for the one who’s lying in the bed.

Scott Rae: Katie, you've mentioned several times how important it is for families to have these conversations with their loved ones about what they would and would not want at the end of life. And we found, I tell this to my seminary students, those are extraordinary, difficult discussions to have. And I have some seminary students who are from some distinct cultures where they just, they rule that just out of bounds. I would never have that, I could never have that conversation with my dad or with my grandfather. So how do you help families actually sit down and have these conversations that are productive and meaningful and actually give guidance to the people who are going to be making decisions for them?

Kathryn Butler: Oh my goodness. So one of my motivations in the book was to try to break that silence, to try to help people understand that as much as discussions of death can stop conversation at a dinner table faster than anything, it's not something that we can defer until the need arises because the stakes are just too high. It's not only suffering on ourselves in terms of enduring treatments that might be abhorrent to us, but it's also inflicting those who are then required to speak for us with incredible, it's just a huge burden. What I would say in terms of trying to coax people to have these discussions, recruit help if possible from a physician. So if you're a child and you're saying, I want to have these discussions with my parent but I can't, you can always reach out to the primary care doctor of your parents and ask them to try to start broaching it. Maybe that difference of a professional opening the discussion will help. Or if there's a pastor that's trusted. And that includes you in the discussion as it unfolds. That would be one way to try to have someone partner with you to try to help open up that dialogue. 

Scott Rae: So they don't-

Kathryn Butler: Another ... Yeah, go ahead.

Scott Rae: They don't get to defer that conversation to the parent, or to the pastor or the physician.

Kathryn Butler: Right.

Scott Rae: But they're included in that themselves.

Kathryn Butler: Exactly. And it's really how it should be. If the next of kin is the one that's making decisions, I would, it should be that they're involved in that discussion. 

And then the next thing I would say is if you're just trying to open that dialogue with a parent, part of it might be actually not to run straight to the scary questions. What would you be okay with? What would you not? But to try to open the discussion about values. What is it that over the course of life they've required to grow in fellowship with the Lord? What has been the most hard for them in life that they would never want to revisit? Start it that way and then maybe refer to someone that you know, that you both know who’s been in the hospital and talk about it in that context about values and suffering. And then get down to the specifics. But make it so that it is a dialogue that's less intimidating. You're not making it obvious that you're talking about death. But really you're trying to get to the heart of what is it that matters to him or her? Because you can then extrapolate those values to help you when you're in a situation of making decisions for a loved one. 

Scott Rae: I thought it was really helpful, your statement, I think sort of early on in the book when you said, "Most of us will be unable to articulate our wishes when the time comes." 

Kathryn Butler: Yeah, yeah.

Scott Rae: That's a major reality check. And something I would hope would be an incentive. If that's true, that I will not be able to articulate my wishes when the time comes, then I'm counting on my loved ones to guess at it if I don't have those conversations with them.

Kathryn Butler: Yeah, exactly. About 70–75% of people across age groups cannot speak for themselves at the end of life and requires someone to speak on their behalf. And that's from illness itself causing confusion or incapacitation. It's from the actual measures that we implement. So, when you go on a mechanical ventilator, you need a tube that goes through your vocal cords. So you literally cannot speak. You require sedation to be able to tolerate the tube. And so then that eliminates nonverbal communication. And oftentimes in severe illness we suffer from delirium, so we're actually detached from reality. And all of these things mean that when there are decisions to be made that are crucial, how far do we go? What do we do? You can't speak and vouch for yourself. And then by necessity the responsibility falls to those you love. And if we don't equip those we love ahead of time with a sense for what we would accept and what would be intolerable, it just puts them through tremendous anguish. 

Sean McDowell: You have a really interesting section where you give advice for people to talk to doctors at the end of a loved one's life. And that's, in some ways, counterintuitive because we feel like when our loved ones are hurting, we're the ones who are vulnerable and they need to know how to talk to us. But you kind of flipped the narrative a little bit. What advice do you have for families talking to doctors?

Kathryn Butler: I mean this comes from having been at the conference table in the ICU so many times where I've had discussions with families. And just knowing that it's very intimidating. And you can have questions banging around your head and not know what to do, but not know what you can ask. And as I mentioned, very few physicians will offer chaplaincy. 

So what I would say first and foremost is ask for spiritual support in the hospital. You're entitled to it. Every hospital offers it. They can help you navigate these things from a spiritual standpoint. You understand how the Bible directs you.

And then in terms of trying to tease out for a loved one when is something reversible or not, just feel empowered to ask questions. Really try to understand what is the disease process that's threatening his or her life. What are the treatments that are being given? And what is their likelihood for recovery and for ushering someone back home? And what are the downsides? And some physicians will volunteer this information. Others will not because they're so caught up in the care itself. And so really feel at liberty to ask questions often and frequently so that you have an understanding of what lies ahead.

Scott Rae: That's really helpful because I know most of the people I talk to in the hospital setting, they're intimidated by talking to doctors. 

Kathryn Butler: Right.

Scott Rae: And they get so little time that it's just, it's really challenging to make those productive. One final question for you Katie. I remember really vividly when my father-in-law left the hospital for the last time. He had had cancer surgery, and I'm wheeling him out of the hospital. And he had been in there for, he had complications, predictably. He was in his late 80s. He was there for probably three weeks. Delirium set in like you described. It was a terrible experience. And he whispered in my ear as I'm wheeling him out, he said, "Don't ever bring me here again."

Kathryn Butler: Mm-hmm (affirmative).

Scott Rae: And I think what he meant by that, he couldn't articulate it quite like that as I'm going, regardless what medicine says or can or can't do, I'm going to live out the rest of my days from the hand of the Lord with gratitude and I'm sort of entrusting myself back to him. 

Kathryn Butler: Mm-hmm (affirmative). 

Scott Rae: What would you, but we were not at a place yet where medicine says we have no more options. But he was done with medicine.

Kathryn Butler: Right, right.

Scott Rae: What do you say to the family who sees that suffering and wants to stop, but it's before the point, I mean everybody's, most people are fine stopping when medicine says we have no more options.

Kathryn Butler: Right, right.

Scott Rae: But before that point, I think is where a lot of the suffering gets inflicted with I would say marginal if little benefit. 

Kathryn Butler: Mm-hmm (affirmative). Mm-hmm (affirmative). Oh, absolutely. You know I would say to the issue of suffering, part of the Christian walk is to have compassion and be merciful to the suffering. And he very clearly declared that what he endured was too much. And we never would have mercy in the sense of actively administering a medication to end someone's life. So that's just assisted suicide. That's not what I'm talking about. But we're not mandated, the Bible doesn't compel us to chase after treatments that are going to cause suffering that's unbearable. And so it's perfectly within someone's power in terms of biblically speaking, to decline further treatments if they say this is too much. 

What I would say for families who are concerned about suffering being too much, it's just really important to tease out what their perception is. And I say this just with a caution because a layperson standing within a doorway of an ICU patient's room can look at that loved one and really not know if they're on the verge of recovery or if they're dying. They will look the same. They can have the same kind of trappings in terms of a ventilator and a big tree with all the IV pumps and a dialysis machine. And you need a physician to try to decipher for you, to decode for you whether or not your loved one is on the verge of recovery or is declining. And so whenever a family brings that question up, I think it's really important to get a clear sense from them about how they think things are going and what's the trajectory. 

And then the next question is, to your point which is to say, okay, even if we do have more options what would the loved one say? If he or she could speak, would they be amenable to this knowing that there's potential for improvements, but would this be too much based on what he's voiced in the past? And it's a really critical question because I've seen two cases that still haunt me. And I wrote about one in the book where it was clear that the discussion had not been thorough, where a family member said, "My mom would never want a ventilator." And it really was not apparent that the mother would decline a ventilator that was to be temporary or short-term. And she had something that was definitely reversible. Would have required a ventilator for only a couple of days and instead the team didn't intervene because the daughter said, "Nope, she never would have wanted it." These things take time to tease apart, okay? If you don't want to be on a ventilator is it really so black and white that it's never? Or is it that you don't want to be ventilator dependent? 

So anytime someone brings up that they think it's too much suffering even if there are further options, it's just important that we tease apart what are really the thoughts at play? And if it really is that they know that this is too much and even if there's hope for cure, this would be too much for them to bear. Then it's okay and compassionate if we're honoring their wishes and their dignity is image there to say, "Okay, we don't have to pursue aggressive measures." 

Scott Rae: That's really helpful. That's really good advice. Katie, I want to commend you for your book and commend it to our listeners. The book's entitled Between Life and Death: A Gospel-Centered Guide to End-of-Life Medical Care. Katie, you've done such a good job with it. It is so well grounded biblically, but it is also incredibly practical. And you've, you take the medical data and put it in layman's terms in really helpful ways that people can grasp hold of quickly and easily. These are really important questions. We've said on our show before that unless you're completely alienated from your family and everybody who you care about, you will walk down this end of life road with someone that you care about. And we will all walk down it ourselves.

So you've done the body of Christ, I think, a wonderful service with this book. And I, I wish you well. I hope our featuring it gets it into a lot of people's hands because it is really good stuff. And I highly commend you for it.

Kathryn Butler: Thank you so much. And I just pray that it helps grant some people some peace in what are just some very, very difficult scenarios. And perhaps can help us remember that ultimately our hope is not in these contraptions that can so scare us and cause suffering, but are in Christ too, will overcome all of it. 

Sean McDowell: Amen.

Scott Rae: Well said. 

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