She groaned at the touch of her abdomen, and in dismay I withdrew my hand. The CT scan showed that her intestines had blackened. Speckles of air signaled rents in her intestinal wall through which bacteria seeped into her bloodstream. Those same bacteria now dragged her blood pressure dangerously low.

I felt a knot tighten in my stomach. An operation to remove her dead bowel was her only chance for survival. Even with an operation, however, her likelihood of leaving the hospital was slim. She had advanced dementia, and prior to this calamity was bedbound, emaciated, and failing in health despite 24-hour nursing care. Her current unstable blood pressure placed her at high risk for dying in the operating room.

“When people cannot direct their own medical care, the hard decisions fall to family members.”

If her fragile body withstood the surgery, she then would struggle with a litany of infections from the bacteria swirling in her abdomen. If we could usher her through those hurdles, removal of so much of her intestines would leave her chronically malnourished, stricken with diarrhea, and dependent on artificially-administered nutrition that would place her at risk for liver failure. I could foresee the long, awful trajectory to which we’d commit her if we operated, a debilitating and painful course that promised suffering, but offered little hope of returning her home.

But to decline surgery meant her family would have to accept her imminent death. In one instant, without time to pray and reflect, they’d have to decide whether to press on and risk suffering for her without benefit, or bid goodbye to the one they cherished. How could they weather such a tragedy?

How can we make such weighty decisions with no time to process and prayerfully contemplate, all while our hearts are breaking? Sadly, far too many of us will find ourselves in just such a harrowing situation.

Asking the Impossible

People facing a threat to life can rarely voice their own wishes. Severe illness disorients, befuddling sufferers with confusion and paranoia. Medical technology further silences the ill, as a breathing tube through the vocal cords or sedating medications eliminate speech. When critical illness so plummets people into silence, they cannot consent to or refuse treatments on their own. The dilemma is common, with one study of people over sixty showing that seventy percent had no capacity to make decisions for themselves at the end of life.

When people cannot direct their own medical care, the hard decisions fall to family members. As “surrogate decision makers,” our role is to honor a loved one as a unique image-bearer of God, and to discern how he would answer, had illness not stolen his voice. The process requires us to step outside of our own wants, to put aside the agony churning in our hearts, and to think about the unique attributes of those for whom we care.

In other words, our goal is to be the voice of our loved one, to answer as he would if he still had the power to speak.

Fallout of Such Decisions

When we act on behalf of a loved one in this manner, we live out our call to love one another as Christ loved us (John 13:34–35). And yet, making urgent medical decisions for loved ones takes a heavy toll on the heart. In the best circumstances, our loved ones will have completed an advance directive (a living will) prior to illness, or at minimum discussed with us their views on suffering at length.

“Making life-or-death decisions for loved ones cripples many with feelings of guilt and doubt.”

The unfortunate truth is that many don’t have these discussions. Only about one fourth of Americans complete advance directives outlining their wishes for the end of life. Without such guidance, when tragedy hits we’re left rudderless, struggling to piece together answers. Making life-or-death decisions for loved ones cripples many with feelings of guilt and doubt that persist for years, and which can progress to depression, complicated grief, chronic anxiety, and even post-traumatic stress disorder.

So how do we make compassionate, Christ-honoring decisions about our loved ones’ care when the unthinkable happens? How do we discern the right path when time to reflect is nonexistent, and when the mind balks at the ramifications of our choices?

How Does God’s Word Guide Us?

As with all facets of life, God’s word provides us with a lamp for our feet (Psalm 119:105). Leaning into God’s word before calamity strikes can help guide us through urgent medical dilemmas with peace and discernment. In particular, attention to the following biblical principles can anchor us when the tempest rises.

1. Mortal life is sacred.

Life is a gift from our Lord that we’re to steward and cherish, glorifying him in everything (Exodus 20:13; 1 Corinthians 10:31; Romans 14:8). We are made in the image of God, and each one of us has inherent dignity and value (Genesis 1:26; Psalm 139:13). The sanctity of mortal life requires that when struggling with an array of medical options, we consider accepting treatments with the potential to cure.

2. God has authority over life and death.

This side of the fall, no one escapes death (Romans 5:12; 6:23). As believers we know that death is not the end, yet while we await Christ’s return, it descends upon us all. When we blind ourselves to our own mortality, we ignore that our times are in his hands (Psalm 31:15; 90:3), and disregard the truth that our Lord works through all things — even death — for the good of those who love him (John 11; Romans 8:28).

3. We’re called to love one another.

God calls us to love our neighbors as ourselves and to minister to the afflicted (Matthew 22:39; John 13:34; 1 John 3:16–17). As God so loved us, so we must extend ourselves in empathy and mercy toward one another (Luke 6:36; 1 Peter 3:8; 1 John 4:7; Ephesians 5:1–2).

“Leaning into God’s word before calamity strikes can help guide us through urgent medical dilemmas with peace.”

While mercy never justifies the active taking of a life (as in physician-assisted suicide or euthanasia), it does guide us away from aggressive, painful interventions if such measures are futile. To pursue treatments in such circumstances may be to strive after the wind (Ecclesiastes 1:14) and to discount our one, true hope — Christ crucified (1 Timothy 4:10; 1 Peter 1:3). Scripture does not compel us to chase after medical interventions if the torment they inflict exceeds the anticipated benefit.

4. Our hope resides in Christ.

As Christ’s disciples, we need not fear death! Even as our lives draw to a close, we cherish the promise of new life (Psalm 23:4; 1 Peter 1:3–4; 1 Thessalonians 4:13–18; 2 Corinthians 4:17–18). We rest assured in Christ’s sacrifice for us and in the awe-inspiring depth of his love (Romans 8:38–39; John 11:25–26). Christ’s resurrection transforms death from an event to be feared into an instrument of God’s grace as he calls us home to heaven.

God’s word guides us to preserve life when illness is recoverable, to accept death when it arrives, and to extend compassion and mercy toward the suffering. These tenets guide us to seek treatments when they offer hope of recovery, but they do not compel us to undergo interventions that prolong death or inflict suffering without benefit. And our greatest hope supersedes any medical technology: it springs from our faith in Christ, and from the grace imparted to us through his sacrifice and resurrection (Psalm 124:8).

Questions to Ask a Doctor

Equipped with the above biblical principles, the next step in navigating medical dilemmas is to unpack the clinical situation at hand. The first task is to determine whether treatment offers promise of recovery, or only prolongation of death. To achieve such discernment, we can ask the medical team the following questions:

• What is the condition that threatens my loved one’s life?
• Why is it life-threatening?
• What is the likelihood for recovery?
• What about my loved one’s previous medical conditions influences his likelihood for recovery?
• Can the available treatments bring about cure?
• Will the available treatments worsen suffering, with little chance of benefit?

These questions are basic and can be explored briefly in an emergency situation. In all circumstances, the key question is this: Is the life-threatening process reversible? When recovery is possible, organ support may offer life, and pursuing treatment is appropriate. In contrast, when a disease cannot be cured or even improved, aggressive measures — surgery, cardiopulmonary resuscitation, breathing machines, and more — can inflict suffering needlessly.

“In all circumstances, the key question is: Is the life-threatening process reversible?”

When the efficacy of treatment is ambiguous, our task becomes more difficult. These moments demand the most courage, patience, and insight from us, even while we flail in grief. The goal is to hear our loved one’s voice, to discern which treatments he wouldn’t endure, and which he would embrace despite the detriment to his comfort, independence, and lifestyle. Such an approach requires that we view our loved one as God sees him: cherished, forgiven, wonderfully made, and unique, with no precise equal on earth (Psalm 139:13–14; Ephesians 1:7; John 3:16; Romans 8:35).

Questions to Ask Ourselves

As the responsibility staggers our minds, another series of questions can guide us:

• What matters most to my loved one? What drives him in life?
• What comments has she made in the past regarding end-of-life care, if any?
• What are his goals? In the short term? For his life in general?
• What is she willing to endure to achieve those goals? What would she be unwilling to face?
• How well in the past has my loved one tolerated pain? Dependence? Disability? Fear?
• If he could speak for himself, what would he say about the current situation?

Such questions, which mine for the unique attributes and values of those in our care, often require stillness and time to explore. In an emergency situation, however, such luxuries evaporate. Our minds race to process all the information hurled at us, in terminology we don’t understand, while our own turbulent emotions cloud our thinking. To assemble a plan under such pressure seems impossible.

Persevere in Love and Prayer

Ideally, we manage to sort through the chaos and discern the path clearly, based upon what a loved one has divulged to us in the past. But if, in the whirlwind of a loved one’s critical illness, we’re just not sure, it’s appropriate to accept treatments in the moment, and then afterward, when matters calm, to deliberate more thoroughly upon how to proceed. Thankfully, in Christ we are forgiven. And God is sovereign even over these terrible moments.

Our responsibility as surrogate decision makers can seem too crushing to withstand. Yet when we seek to hear our loved one’s voice after it has fallen silent, we honor and love him. In so doing, we also honor God the Father. Although the burden threatens to crush us, when we persevere in love and prayerfulness to support our loved ones in their critical moments, we live out the gospel.