LCMS Convention Workbook St. Louis, Missouri — 2026, Page 202

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THEOLOGICAL DOCUMENTS­­—COMMISSION ON THEOLOGY AND CHURCH RELATIONS
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7. “Vegetable” vs. “Persistent Vegetative State”
Lay use of the term “vegetable” for a person in a coma or a vegetative state represents a horrible misinterpretation of the
meaning of the medical term “persistent vegetative state” (PVS). While the word may be acceptable within the scope of its
clinical use, the casual use of it may mislead people greatly. The term “coma” refers to the lack of both awareness and wakefulness, whether in an open-eyed or closed-eyed coma state. Patients in a vegetative state may have regained consciousness
from a coma, but still have not regained awareness. PVS represents a disorder of consciousness in which patients with
severe brain damage are in a state of partial arousal rather than true awareness. Typically the classification of “vegetative
state” (VS) gets applied to such persons in the first weeks with the classification “persistent vegetative state” coming after
four weeks. While some commonly describe those in a persistent vegetative state as brain dead, that misunderstands the
injury. Patients with PVS have a healthy and functioning lower brain stem.

United States, the term “hospice” often denotes facilities and institutions. Usage in the United States applies to both in-patient and out-patient (home-based) programs that began to spring up and proliferate in the early 1970s. In 2017, almost 1.5
million patients took part in hospice in the United States.

Although very rare, PVS patients may sometimes regain full consciousness. One man, Conley Holbrook, was classified as “comatose” for eight years. On Feb. 25, 1991, he awakened. According to Bartlett and Rehder, 26-year-old Holbrook
was not only able to call each of his relatives by name, but he was even able to identify the small children who had been
born while he was unconscious.140 Another person, Patti White Bull, emerged from her unconscious state on Christmas
Eve in 1999 after 16 years.141
8. What Do/Did They Want? vs. What Is Best for Them?
As Christians, the question “What did he/she want?” should not be primary in our thinking. A better question for
Christian surrogates at the bedside of a dying loved one should be, “What is best for this person?”142

H. Hospice Care

Hospice care, in-patient or at home, can become a valuable partner to both the family and the dying person. Unlike health
restorative therapies and procedures common in hospitals, hospice aims at palliative relief of pain and symptoms of a terminally ill patient.143 Hospice programs also incorporate attending to the emotional and spiritual needs of the patient. Note
that the spiritual support provided by a secular organization that conceives of the idea of “spiritual” in the most generic and
ecumenical way will be something quite different from pastoral care offered by a Lutheran clergyman.144 Lutheran pastors
will want to provide Word and Sacrament ministry to a terminally ill person on a regular basis. They will typically want to
prepare the dying saint and his or her family for impending death with the use of the “Commendation of the Dying,” found
in the Pastoral Care Companion.145
Because of the focus on palliation of a terminally ill patient’s pain and symptoms, the priority falls on comfort and
quality of life through the reduction of pain and suffering. Hospice provides an alternative to therapies aimed at prolonging life through means of therapies and procedures. Current treatments for cancer, for instance, carry with them potential
unwanted side effects and additional symptoms that may prove extremely burdensome to an elderly patient. Outside the

At present, the United States Medicare program only covers hospice care if the hospice provider is Medicareapproved. One can determine if the hospice provider qualifies as Medicare-approved by inquiring with your physician,
the hospice provider, the state hospice organization or the state health department.146 If the hospice has been Medicareapproved, “once your hospice benefit starts, Original Medicare will cover everything you need related to your terminal
illness.”147 Current law permits two 90-day benefit periods, followed by an unlimited number of 60-day benefit periods.
This includes the right to change hospice providers once during each benefit period.
Depending on the specific needs of the terminally ill person, the number and quality of hospice programs in the
area, and one’s own ability to assist in the care of the dying loved one, a person may prefer to opt for receiving hospice in
a nursing home or long-term care facility where hospice services are added onto the regular nursing, housekeeping and
dietary services. Most people profess to prefer dying in “my own bed” rather than in a hospital, nursing home or other
institutional setting. However, if the spouse may be too frail or impaired to assist the hospice team actively, an in-home
program may not be practical. At times, the decision whether or not to use home-based hospice will hinge on the availability of family members (and/or hired help) to support the terminally ill person. A frail, elderly spouse suffering from
early stages of dementia, for instance, would not be a suitable person to attend to an obese patient with uncontrolled
incontinence.
Increasingly, patients are encouraged to become intelligent consumers of their usage of medical science and its myriad
benefits. In the area of hospice, differences of practical pain and symptom management exist. For instance, some hospices
may not perform glucose monitoring for diabetics as they see it as “treatment toward a cure,” even though not monitoring
glucose could cause hypoglycemia (critically low levels where a patient goes into coma and death) or hyperglycemia (critically high levels). Both are considered clinical emergencies. Other hospices recognize glucose monitoring is not curative,
but that it prevents harm in maintaining acceptable levels and waiting for death from another condition (e.g., cancer, heart
failure). Asking questions of the staff before entering into an agreement may assist patients and their families in making
a wise selection. And while the Medicare website declares that “Original Medicare will cover everything you need related
to your terminal illness,” that should not be understood to mean that nothing is expected of the family. Different hospice
providers carry out their duties in myriad ways, some handling most of the care needs, others expecting family members
or the hospital or senior facility to shoulder some of the responsibilities. Again, asking enough questions in advance and
probing to ensure a full understanding of how a particular organization operates will increase the likelihood of having a
satisfying relationship with their services and support in a time of need. Note that a person is not obligated to accept the
leads and recommendations from hospital discharge planners. While they may be invaluable in a search for a provider,
their information should not substitute for one’s own efforts to secure the hospice that will meet the family’s expectations.

140
Bartlett and Rehder, “Ventilators, Feeding Tubes, and Other End-of-Life Questions,” 5. Conley Holbrook identified his cousin as his attacker following awakening from his semi-comatose
state, resulting in the man facing trial for attempted murder. “Brain-Damaged Man’s ‘Miracle’ Recovery Lands a Cousin in Jail: Tragedy: The Two Boyhood Chums Grew up to Be Drinking
Buddies. A Head Injury Left One of Them Speechless for Eight Years. Was It Assault or Just Another Family Fight?” Los Angeles Times, April 21, 1991, latimes.com/archives/la-xpm-1991-04-21mn-846-story.html.
141

“Awakening from 16 Years in near-Coma.” Los Angeles Times, Feb. 3, 2000, latimes.com/archives/la-xpm-2000-feb-03-me-60571-story.html.

142

This point is discussed in more detail under the section on advance directives, particularly as related to the durable power for health care proxy (see pages 17–21).

The very notion of hospice care stands against the ideology of suicide and euthanasia. As Dyck notes, “Hospice was founded to provide comfort-only care that would help prevent suicide and
euthanasia. Hospice physicians repeatedly report that once they provide comfort-only care, patients who expressed a desire to end their lives, or have it ended, change their minds, or no longer
pursue ending their lives as an option,” Life’s Worth: The Case Against Assisted Suicide (Grand Rapids: Eerdmans, 2002), 47.
143

144
Hospice organizations may assume that they will be responsible for the spiritual care of the dying person. It may be necessary for the family to request that their pastor rather than the hospice
chaplain provide spiritual care and counsel for the dying.
145

“Commendation of the Dying,” in Lutheran Service Book: Pastoral Prayer Companion (St. Louis: Concordia Publishing House, 2007), 81–94.

146
Because Medicare Advantage programs must offer the same benefits as traditional Medicare, one may also take advantage of hospice through a Medicare Advantage program. However, the list
of providers will be limited to those approved by the Advantage program. “How Hospice Works,” Medicare, medicare.gov/what-medicare-covers/what-part-a-covers/how-hospice-works.
147
Coverage may not be as complete as some expect. For more information about what Medicare considers “everything you need related to your terminal illness,” see “How Hospice Works,”
above.

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PA S T O R A L A N D S P I R I T UA L D I M E N S I O N S

Medicare suggests that the following questions may aid families in the selection of a hospice provider:
• Is the hospice provider certified and licensed by the state or federal government?
• Does the hospice provider train caregivers to care for you at home?
• How will your doctor work with the doctor from the hospice provider?
• How many other patients are assigned to each member of the hospice care staff?
• Will the hospice staff meet regularly with you and your family to discuss care?
• How does the hospice staff respond to after-hour emergencies?

IV. Pastoral and Spiritual Dimensions

• What measures are in place to ensure hospice care quality?
• What services do hospice volunteers offer? Are they trained?148

A. Dealing with Our Uncertainty and Sinfulness

The discussion of end-of-life decision-making must also take account of the ambiguity inherent in all human experience.
As fallible creatures with circumscribed consciousness, we must admit that we may not always know clearly what the
“right thing to do” might be in a particular situation. More than one disciple of Christ has felt the force of St. Paul’s phrase
“we see in a mirror dimly” (1 COR. 13:12) when confronted with the uncertainties attending to bedside decision-making for
a dying loved one. After opining that the unbroken tradition from “Genesis to Heidegger” differentiates animal life from
human life by the presence of “human consciousness of self,” Thielicke admits that there are no casuistic rules to offer us
infallible direction on how to handle the bedside choices families and physicians must render. He resorts to the notion that
“one must simply run the risk of making the decision — and be prepared in so doing to err, and thereby to incur guilt. As
a Christian, I would say that whoever hopes to come through it all without illusions or repressions will have to live in the
name of forgiveness.”149
The 1993 document of the CTCR reminded us that “any decisions made in this highly complex area, and any actions
taken that may later appear to have been wrong, have been redeemed by that forgiveness which is available to all who put
their trust in the work and merits of mankind’s Savior and Redeemer.”150 To sinners burdened in conscience by the guilt of
the Law, our final word must always be one of Gospel and forgiving grace in Jesus Christ. Whether hindsight reveals the
inadequacy of our calculations here or not, we dare not stop with the penultimate word of Law but press on to the ultimate
word of Gospel. As Luther wisely observed, “Are we to rate the price of his blood so low as to say that it has redeemed only
what is lowest in man, and that what is most excellent in man can take care of itself and has no need of Christ?151
At one level, such counsel should reassure those who confess that all human efforts carry the taint of sin and that
motives can never be 100% pure. We all live by faith and in light of the forgiveness of God, after all. For faithful loved ones
carrying a burden of guilt over the death of a loved one and torturing themselves over whether they could have “done
more” or done it differently, this message may be an important part of sensitive pastoral care.
One can hardly gainsay the liberating promise of divine forgiveness and the blessed state of absolution. However, we
are never permitted to substitute divine pardon for legitimate human agency. We dare not adopt a cavalier attitude that it
does not really matter what we decide to do since we know that God will forgive us in the end anyway. Neither are families
exempt from the difficult prayerful conversations that attend to living in Christ through faith as we serve our neighbor
through love.152

148

“How Hospice Works,” medicare.gov/what-medicare-covers/what-part-a-covers/how-hospice-works.

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149

Thielicke, The Doctor as Judge, 21. See the entire section, 16–21, for his argument.

150

CTCR, Christian Care at Life’s End, 21.

151

LW 33:227.

In Luther’s “The Freedom of the Christian,” he writes: “We conclude, therefore, that a Christian lives not in himself, but in Christ and in his neighbor. Otherwise he is not a Christian. He lives
in Christ through faith, in his neighbor through love,” LW 31:371.
152

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