Being involved when life and death hang in the balance

18 MINUTE READ

From Luke’s Journal 2021 | Dying & Palliative Care | Vol.26 No.2

Repeatedly and consistently, I pleaded with my patient to persevere. I brought all of my resources and every last bit of my interpersonal capacity to bear.
It wasn’t enough.

His wife is now widowed and his adolescent children are fatherless.

We met about two years ago, and I cared for him over eight consultations, spanning two short months. My friend, an experienced medical practitioner, had been pastorally caring for him at church and asked me to consider taking over care from his regular GP. From the outset, his clinical situation was complex and hard to traverse. He was recently afflicted by an untreatable disease which had suddenly and utterly taken away his vision. He was no longer able to work, to provide for his family. A deep, melancholic depression set in. From the outset he was sharply offended when I enquired about suicidality. Suicide was unthinkable to him in light of his faith and his love for his family.

He was very difficult to treat as his depression continued to relentlessly deteriorate. As his hopelessness and despair mounted, his willingness and capacity to engage therapeutically diminished. I was increasingly concerned about the very high risk of suicide, but I struggled to access additional help. Because he was uninsured and newly unable to work, he felt very resistant to engage a private hospital for admission. He was categorically unwilling to have a public psychiatric admission. It would not have been possible to have this very intelligent man admitted under the mental health act without the definitive backing of his family for such a decision. As he deteriorated, medications started by me sharply worsened his agitation from the side effect of severe akathisia. I was extremely worried about him, concerned for his life and saw him at least weekly during this sharp deterioration in his depression.

“ I was extremely worried about him, concerned for his life and saw him at least weekly during this sharp deterioration in his depression.”

But then the medications began to work. His mood began to lift. For the first time, I started to see his personality emerge, his dark humour, a sense of hope. I started to feel hope too. I recall my last consult with him, it was the first consult where his wife felt he was safe enough to let him attend alone. This patient was amongst a very small group for whom I have appreciated suicide was of grave and almost imminent concern. But increasingly over time and in our last consultation particularly, my own hope started to emerge, “I think that he is going to pull through this”.

And then, within days, he took his life.

Losing him was a deep shock. A sorrow-filled blend of disbelief, sympathy and frustration at the squanderous nature of such a death and anger at the abandonment of his family. His death rattled me to the core.

Suicidality in General Practice

In my 14 years of work in General Practice, I have always carried a disproportionate load of suicidal patients. Out of Christ-inspired conviction I’ve actively sought to take on the care of patients that many colleagues prefer to avoid. This has meant caring for far more people with complex mental health issues, family and social problems, addictions, homelessness and other difficult situations. It would be very rare for me to have a working day without at least one substantially suicidal patient. As a result, I have developed ways to be there for them, to estimate risk, seek appropriate support, involve the people in their lives and other clinicians. Naturally, I do all that I can in the consult: challenging patients to push back against suicidality, to resist fantasising or dwelling on thoughts of dying and means of dying, to have a clear rebuttal against any reasons to die. I often am quite personal in exhorting patients to carry on and plead with them to carry on for the sake of loved ones. I express a commitment to stay alongside them through the process of recovery until we can look back on suicidality as nothing but a memory.

Despite all of my efforts, I recognise that nothing I can do can keep a person safe. Historically I have had to prayerfully entrust each one of my suicidal patients to the Lord. If my counsel is of any benefit to a person, to persuade them to live, to counter the lies of the Enemy, to be comforting in the midst of a harsh depression, surely it is the Lord working through my words by the wisdom He has provided. At the end of the day I never remain with my patients, they are in God’s hands. I’m not omniscient or omnipotent, but God is. God numbers our days, and I am reminded that not a single sparrow falls to the ground without the sovereign control of the Lord (Matt 10:29). Thus far in General Practice, God has responded to my meagre trust in Him by enabling me to not be ridden with anxiety for each of my profoundly worrying patients. 

And yet, this patient’s death was really hard to reconcile. So many of my most dangerously suicidal patients are young and impulsive, misusing alcohol and drugs, separated from family and socially isolated with either highly abusive friendships or none at all. But this patient was different. Of all the suicidal patients I can recall caring for he had the most support. He had a loving and highly involved wife, dependant but connected adolescent kids, a good circle of committed friends, a lovingly involved and pastorally geared church with regular support from his pastor, his medical church friend and numerous other people in his church family. He expressed a genuine faith and robust rejection of suicide as theologically unacceptable to him. That he died amongst all this support made me question who could be safe. He died despite a steady stream of the best kinds of support.

Compounding the hardship of his death was all of the difficult conversations that lay ahead. I spoke to his pastor and his medical church friend who had referred him. What should I have done differently? Not knowing I had been his doctor, many of his church family and people from the local Christian community came seeking professional care from me about their grief over the loss of their friend. I was reminded afresh at the immense pain radiating from this tragic loss of life. About a year later, his widow was ready to bring her own questions about the last consultation, about his care, his death and trying to make sense of the unexplainable. How I wish my patient had pulled through! Although nearly two years have now passed, his death is rarely far from my mind. The inexplicable and uncertain threat of suicide often causes me to recall the death of this patient when I experience worry for other patients with concerning suicidal thinking.

I still grieve the loss of my patient, but not as one without hope (1 Thes 4:13-18). With certainty, I know that I will see my brother again; his vision and joy made perfectly complete by our Saviour.

Some Biblical vantage points on suicide

Scripture encourages us to expect brokenness, pain and suffering in our fallen world.¹ We expect times of overwhelming grief and darkness.

As examples, the book of Ecclesiastes portrays the pain of life’s seeming futility and Job gives us a precious vantage point of a life in ruins under God’s watchful sovereignty. Completely “acquainted with grief” and “stricken, smitten by God and afflicted” (Isa 53:3,4), Christ, our Great High Priest is able to sympathise with us in our weakness (Heb 4:14-15). Christ himself experienced excruciating loneliness in his suffering saying “My soul is very sorrowful, even to death” whilst his disciples couldn’t even remain awake for him (Matt 26:28-46). Yet, no Christian will ever have to experience Christ’s utter estrangement from God as he died on the cross. Despite this, the suicidal person may feel a sense of emotional familiarity with David’s foreshadowing of Christ’s isolation and suffering in Psalm 22:1-2: “My God, my God, why have you forsaken me? Why are you so far from saving me, from the words of my groaning? O my God, I cry by day, but you do not answer, and by night, but I find no rest.” 

Part of the potency of suicidal thinking is the extreme, categorical belief that ‘things will always be this way’ and that ‘I will never recover’. There is entrenched helplessness and utter hopelessness. When not feeling suicidal, Christians can more readily identify such thoughts as the deception of Satan, who is by his nature “a murderer, … a liar and the father of lies” (John 8:44). Satan wants us to believe the heinous lie that it is worse to live than die. Contrast this with the life-giving words of our Creator and Redeemer: “I will never leave you or forsake you” (Josh 1:5, Heb 13:5). And Jesus’ parting words “Behold, I am with you always, to the end of the age” (Matt 28:20). The always and never of suicidal thinking are anaemic falsehoods when contrasted with the always and never of God’s faithful love for all who believe. 

“Despite all of my efforts, I recognise that nothing I can do can keep a person safe.”

There are remarkable similarities between the worldviews of the non-Christian and the suicidally depressed Christian; “The experience of unbearable pain, interpersonal alienation and hopelessness is similar. The struggle with unmet felt needs and the belief that there are no solutions to their problems is the same.”² The difference is that we know God, and it is essential that we don’t ever lose sight of him, especially in the midst of relentless hardship. God calls us to completely trust Him even in our pain and sorrow. He calls us to trust His promises and His character beyond what we can see and comprehend about our current situation and our future.

Consider Romans 8:38-39, “For I am sure that neither death nor life, nor angels nor rulers, nor things present nor things to come, nor powers, nor height nor depths, nor anything else in all creation, will be able to separate us from the love of God in Christ Jesus our Lord.” This passage ought to both comfort and assuage the pain of a person considering suicide and also serve to reassure those of us who have lost a believer by their own hand. 

Without a doubt, the Bible forbids murder, including self-murder.³ Suicide is a morally blameworthy and culpable choice no matter how grievous the context. Scripture’s references to suicide are universally negative, and each occurs in the midst of utter shame and sinful ruin.⁴ God refuses every pleading request of Moses, Elijah, Jeremiah, Jonah and Job to take their lives.⁵ For Jonah and Job particularly, God is highly critical of their plea. In an extraordinary article, Julie Gossack, who lost five family members to suicide, powerfully articulates,

“Suicide is a sinful choice by an individual. This statement is neither unloving nor disrespectful. It is the truth. I dearly love my family members that committed suicide, but their choices were sinful and not righteous … My family members believed the lie that their pain was greater than they could handle and that they deserved better than what God was giving them. They focused on relieving their own pain rather than considering the anguish they would do to surviving loved ones. They esteemed themselves above others. They failed to see God’s goodness or sovereignty in their circumstances. Rather they put themselves in the place of God, the holder of life and breath, and decided they themselves were the holder of life and breath. They chose to lean on their own limited understanding and perspective instead of God’s.”⁶ 

We are reminded that “God is faithful, and He will not let you be tempted beyond your ability, but with the temptation He will also provide the way of escape, that you may be able to endure it.” (1 Cor 10:13b). Paul provides a great example amongst others in Scripture who are wearied by the circumstance of life: “We were so utterly burdened beyond our strength that we despaired of life itself. Indeed, we felt that we had received the sentence of death. But that was to make us rely not on ourselves but on God who raises the dead. He delivered us from such a deadly peril, and he will deliver us. On him we have set our hope that he will deliver us again.” (2 Cor 1:8–10)

“More than any other factor, hopelessness is the single strongest predictor of suicide.”

However tragic, suicide is ultimately a sinful means of self-centred rationalisation. Other sinful styles of thinking commonly abound in the suicidal person; anger, unforgiveness, bitterness and prideful entitlement. More than any other factor, hopelessness is the single strongest predictor of suicide. Hopelessness represents a sense of certainty that no solution exists, no escape, no good outcome – that all is lost. The future offers only misery, dread and despair. In contrast to faith, hopelessness fails to recognise the goodness, timing and wisdom of our sovereign God. Rather than death being the goal, suicide is often the means as a very tragic approach to stop seemingly unendurable suffering.

Suicide and Salvation

It is important to emphasise that despite its sinfulness, suicide does not nullify salvation. To doubt God’s ability to forgive suicide, is to doubt Jesus’ ability to atone for sin at all. Because all sins are covered by Christ’s atoning death on the cross, there are no sinful circumstances leading to death which will remove a Christian’s standing before God. The fact that suicide is the final act of life, doesn’t invalidate the efficacious sacrifice which Christ has accomplished. “One dark moment in a Christian’s life cannot undo what Christ did for us on the cross … Romans 8:38 reminds us that nothing will ever separate us from the love of God … When you stand before God, you won’t be judged by the last thing you did before you died but by the last thing Jesus did when He died.”⁷

God will witness evidence of a believer’s faith throughout the entirety of our lives, not just our final minutes.⁸ Mercifully, believers will be judged on the righteousness of Christ’s life and death, rather than the unrighteousness of our own. Believers can still commit suicide, remain forgiven and spend eternity with the Lord.⁹

Losing people to the lies, hopelessness and half-truths of suicide should make us desperate to run to our loving Father for comfort. Our remedy is to trust in God’s character and promises, to put on the full armour which God has provided us and to remain held fast by our Saviour in His great salvation as we await the day in which:

“He will wipe away every tear from their eyes, and death shall be no more, neither shall there be mourning, nor crying, no pain anymore, for the former things have passed away”. (Rev 21:4)

How will I care for my next suicidal patient?

In addition to the normal medical cares, exploring history, circumstances and mental state, for my Christian patients I will aim to remind them of essential biblical truths which may have been clouded by depression. I’ll seek to impress on them that Satan is a liar and a murderer (John 8:44) who lies because he wants to destroy you (1 Peter 5:8). I’ll implore them “Don’t listen to the liar. Listen to Jesus, the truth teller”¹⁰ (John 8:32; 14:6). I’ll encourage them not to usurp God’s responsibility, and certainly not to seek a terrible ending to their life which will horribly impact their family. 

For the non-Christian, I will suggest that no matter how they feel, that I am persuaded that genuine unshakable hope exists. That I will commit to walking with them while we manage their distress and seek out that hope. I will try to share the hope of the Gospel even in simple, brief references. I will pray for them, that God will reveal himself to them for the first time, or minister to them again. And whenever possible I will pray with them, a dynamic that is very regularly appreciated by non-Christian patients. These are once in a lifetime consults for most patients; to feel so severely unwell, to have disclosed so much. To offer prayer communicates that they are not alone – another person cares profoundly, and there is a God who will hear their cries too. Literally holding a person’s hand as I reintroduce them to their Maker, I demonstrate how they themselves can reorient their sorrows, together we take a step in healing and recovery. 

“To offer prayer communicates that they are not alone – another person cares profoundly, and there is a God who will hear their cries too.”

It is hard to imagine that I won’t have other patients die by suicide. Having done all I can with my patients, it is good to entrust them to the Lord. Unlike me, He is available and accessible 24/7. Unlike me, our loving God is infinitely wise, powerful and good. Unlike the finite public and private psychiatric support I seek for patients, God will never turn anyone away. What a relief that I can confidently refer all of my most life-threateningly suicidal patients to Him. 

As I petition God to do all that He wills and works in the life of my patients, I know that he is teaching me to love and care well. It is extraordinary that the Lord grants me the privilege of being involved in His work in people’s lives, even when life and death hang in the balance.

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