TERESA CLEMENTS, RN: Who or what helps you when you face serious challenges in your life?

CURTIS NELSON: I always get comfort from Audrey, my wife.

CLEMENTS: Of 61 years.

CURTIS NELSON: Yes, of 61 years, yes. And then our pastors.

CLEMENTS: So your faith is important?

NELSON: Yes, very important.

LUCKY SEVERSON, correspondent: Conversations like this at Gundersen Lutheran Hospital in La Crosse, Wisconsin, are what set off the nationwide outcry over the so-called “death panels.” This is Curtis Nelson, connected to a dialysis machine, with his wife Audrey and his son Dennis. Teresa Clements is a nurse guiding the discussion.

CLEMENTS: With your particular illnesses, and you’ve got the multiple myeloma, the heart failure, and now the kidney disease, it’s difficult to predict when a complication can occur, and it can happen suddenly, and you might not be able or aware to make those decisions.

SEVERSON: These end-of-life conversations began in the 1980s at the urging of the hospital’s medical ethicist, Bernard Hammes. He had grown alarmed after listening to staff doctors distressed about how to treat incapacitated terminally ill patients.

BERNARD HAMMES (Clinical Ethicist, Gundersen Lutheran Health System): What does the patient want me to do? The patient now is too sick to ask, the family, when we ask the family, had no idea what the patient would or would not want, and so we were really faced with this moral or ethical dilemma.

SEVERSON: And when the doctors don’t know what the patient or the family wants, Hammes says there’s only one thing to do.

HAMMES: Here, anywhere in the world quite honestly, when you have a patient coming into a hospital who’s very ill, maybe dying if we don’t treat them, our assumption is that treating, attempting to prolong life is the right thing to do. And that, indeed, from an ethical, professional perspective is the right thing to do, but is it what the patient would want?

CLEMENTS: You have a serious complication from your kidney disease, you have a good chance of living through the complication, but it’s expected you will never be able to either walk or talk or both, and you would require 24-hour nursing care. You would choose the following: to continue all treatment because living as long as possible is most important; you would stop all efforts, including dialysis to keep you alive because your quality of life is more important than your quantity; or you are not sure.

NELSON: That would be terrible. I wouldn’t want to have that.

CLEMENTS: So to stop all efforts then.

NELSON: Yes, if I got into a position like that, yes.

SEVERSON: In La Crosse, Wisconsin, 96 percent of the patients who die have gone through these advance directive discussions and designated how they would prefer to spend their last days.

HAMMES (lecturing): This program is not trying to talk people out of treatment. This program is trying to help patients make informed decisions so that we know what they would want even in a crisis, and we can deliver the services that match their preferences.

SEVERSON: The program has been so successful representatives from around the country now attend seminars at Gundersen Lutheran. The success is due, in part, to the backing of the Catholic and Lutheran churches. A similar program is underway in Minneapolis-St. Paul, which is supported by the head of the National Association of Evangelicals, Pastor Leith Anderson of the Wooddale Church outside Minneapolis. He says he witnessed too many families going through emotional turmoil when their loved one was dying.

REV. LEITH ANDERSON (President, National Association of Evangelicals): For the family, that there are processes in place is wonderfully helpful because often children and spouses, they’re frightened, they don’t want to make a mistake, they don’t want to give up too soon, they don’t want to hold on too long, and if it’s been discussed, and especially if it’s been documented in writing, that is really a gift to family.

SEVERSON: Pastor Anderson says both he and his wife have filled out advance directives, and he’s encouraged members of his congregation to do the same. The directives, he says, are biblically based, and he uses as an example the story of Jacob when he knows he is about to die.

ANDERSON: And it tells about him bringing all of his sons around him, and he gave a prepared statement to every one of them, and it was different for each one. But the Bible line in Genesis 49 says that he gave instructions. Now that’s marvelous. Here long ago was a man who knew he was going to die and gave final instructions.

SEVERSON: Advance directives today detail individual treatment, assign power of attorney, and are available electronically. Hammes says they are not “death panels,” a description he says is “simply a lie.” He says some people choose to stay alive with any technology medical science can offer. A majority request less invasive treatments. Some, because of their religious views, are ready to meet their maker.

CLEMENTS: If those hopes don’t come true, what else would you hope for, Curtis?

NELSON: That the good Lord says I can come in.

CLEMENTS: That the Lord says you can come in?

NELSON: Yeah.

SEVERSON: The hospital now trains social workers, nurses, and pastors to conduct these discussions. Bernard Hammes has filled out his own.

HAMMES: I’m not making a judgment for you or for anyone else, but I think we live in a world in which we have to share resources. That’s a spiritual value for me. So if I receive medical care, and it reaches a certain stage, and it’s not going to change the outcome for me, but a lot more money could be spent, I would say, you know, the cost of this care has reached a point that I no longer feel is ethical, because other people don’t even have basic needs being met.

SEVERSON: Although it wasn’t the original intent of Gundersen’s advance health-care planning program, there has been an additional benefit. It saves money. Typically, hospital costs for a patient’s last 6 months of life nationwide average about $31,500. At some hospitals it’s twice that amount or more. At Gundersen Lutheran it’s $22,000 because the patient spends fewer days in the hospital.

HAMMES: Where would you rather spend your time if you had two years left to live, in the hospital going through tests and procedures? We’re putting many, many patients in this country through a lot of additional suffering and expense, some of which they’re going to have to pay for. It’s the fourth most frequent reason for families to go bankrupt.

SEVERSON: There’s another reason hospital costs are less. Doctors here are paid a salary. Dr. Jeff Thompson is CEO of the Gundersen Lutheran Health System.

DR. JEFF THOMPSON: In our organization and others like us, a physician gets no extra money because they do a CT scan or lab work. There’s no added incentive to put patients in the hospital.

SEVERSON: Dr. Greg Thompson, a pulmonary critical care specialist, says these days the intensive care ward mostly treats patients who have a better chance of long-term survival.

DR. GREG THOMPSON: Many of those patients who have the underlying terminal disease don’t even come to the intensive unit, because they have already decided that at this point in their life that’s not the level of care that they want. They want care, but not the critical care that they would receive in a critical care unit.

ANDERSON: I think that there’s a growing number of people who do not want to have a lot of tubes connected to them. I would say that increasingly I am hearing people say, “I want to die at home.” So they’re making a choice that dignity is more important than more days.

CLEMENTS: Any other hopes for you guys?

DENNIS NELSON: Oh, I would hope that he would get off from this, and if it is eventually going to happen, that it wouldn’t be a long, drawn out process in passing so.

CURTIS NELSON: That’s the biggest thing. I don’t want it to have it dragged out.

TERESA NELSON: So this is a good conversation to have.

SEVERSON: In these discussions, talk is about practical things but often turns deeply personal.

HAMMES: People don’t like talking about death. It’s a taboo in our society. This is a very intimate conversation. When you talk about these issues, you’re really talking, if you will, about the meaning of life, about your religious beliefs and faith, and ultimately about who you are, and that’s a little frightening to most of us.

SEVERSON: At the end of these discussions, Hammes says he often hears the same thing from the nurses and facilitators who conduct them.

HAMMES: What they will report to me is that what they experienced was a sacred space. What happens in families when they really get into the meaning of this conversation is they tell each other how important they are to each other.

SEVERSON: The idea of advance directives appears to be gaining traction. Intimate discussions about the end of life are now starting to take place in hospitals around the country.

For Religion & Ethics NewsWeekly, I’m Lucky Severson in La Crosse, Wisconsin.

LUCKY SEVERSON, correspondent: This is the Mormon Church’s Crystal City Chapel just outside Washington, DC. There are several others in the area, but this one is unique: the 800 members who attend here are all single. Along with worshiping, they’re here for one other very important reason: to find a partner and get married.

This is Bishop Lewis Larsen, who leads a congregation of older singles aged 31 to 55.

BISHOP LEWIS LARSEN: If you were to look across the general spectrum of single adults, the trend in America is not to even marry at all but to cohabitate. That is not a trend in the Mormon Church.

SEVERSON: If there’s any doubt, talk to some of the singles here.

ADAM NILSEN: I know that God wants that for me. I know that man was not meant to be alone, nor was woman, but that we complement one another.

SEVERSON: Were you ready at 22-23 to get married?

DARLA MARBURGER: I sure think I was. I think I’ve been ready for a long time, but I haven’t been plucked from the vine yet.

BEVERLI JO DEWALT: My grandma offered to find someone to pay someone to date me, because she was fairly convinced I was not able to do that on my own.

PROFESSOR BRAD WILCOX: Mormonism is the marriage religion.

SEVERSON: Sociology professor Brad Wilcox is director of the National Marriage Project at the University of Virginia. He says the marriage rate in the US has seen a dramatic decline since the 1970s at a 14-fold increase in couples cohabiting. But among practicing Mormons, marriage is still sacred.

WILCOX: They sacralize marriage, obviously, and they view marriage as an eternal institution that exists beyond this space and time.

SEVERSON: Professor Wilcox is speaking about temple marriages, where members in good standing are sealed together for time and all eternity.

LARSEN: When you die and your spouse dies, you will be united as a husband and wife. When your children die, they will be united with you as a family and that the family unit continues on, and I know that that’s a concept that is not generally taught in the Christian world, but it’s very sacredly held concept in Mormonism.

SEVERSON: Marriage has always been a sacred principle of the Mormon Church, but it took on an added dimension when church president Thomas Monson, who is considered a modern-day prophet, expressed alarm at the church’s most recent general conference that not enough members are getting married.

PRESIDENT THOMAS MONSON: Now I have thought a lot lately about you young men who are of an age to marry, but you have not yet felt to do so. I see lovely young ladies who desire to be married and to raise families, and yet their opportunities are limited because so many young men are postponing marriage.

SEVERSON: One reason church leaders are pushing marriage so urgently is that so many young men in the mid-20s are falling away and becoming inactive, focusing on the kinds of things that occupy other young men—getting an education, a job, and having fun.

It’s important to the church and to its young men that they get married, because only married men can hold high leadership offices, and the church says only Mormons who marry can reach the highest realm in the afterlife.

Since serving a church mission, many young Mormons in the DC area have spent their time pursuing advanced degrees. Beverli Jo DeWalt has been working on a career at the State Department.

DEWALT: Most of the folks out here are people that have pursued an education, pursued a career and not with the purpose of delaying marriage, but with the idea that we want to have a full life that includes all of those things.

SPENCER WILLIAMS: I’ve been just very busy with business, and it wasn’t until about six months ago when I really decided I do want to get married.

SEVERSON: How about you, Steve, what’s your excuse?

STEVE ARCHIBALD: Well, beyond the obvious or…?

SEVERSON: Steve Archibald is 28, has a master’s in accounting.

ARCHIBALD: There’s definitely a lot of pressure to get married, but at the same time there’s not pressure to rush into any kind of decision. We can all say that we’re looking. We’re doing our best to try and find the potential “10” out there.

SEVERSON: One high church leader suggested that in looking for a mate, young Mormons like Steve should stop reaching for a “10.“

LARSEN: It’s my job as bishop is to bring a little reality on this, that what they thought they were going to marry probably never did exist. You know, people have faults. Some might be a little overweight, some might be losing their hair, and that doesn’t mean that they are not a fantastic person.

SEVERSON: This is an annual social event in Washington for single Mormons aged 31-55. Washington may not be the hub of the church, but there are between 50,000 and 70,000 members living in the area, the largest concentration East of the Mississippi. For women in their mid-30s who want to start a family, more and more are taking the initiative.

LARSEN: We are a traditional church, and you would say women don’t initiate. But I think that changes when you’re around 30. Yeah, women are much more proactive in my ward.

NILSEN: Having lived in other places I’ve seen other cultures, that women that do take a lot of the initiative.

SEVERSON: So have you had it happen to you?

NILSEN: Have I had women take the initiative with me? Yeah, absolutely.

SEVERSON: Thirty-four-year-old Beverli Jo DeWalt says she is now ready.

DEWALT: I had the opportunity to be married when I was 21—a great guy, a fantastic guy—but I didn’t feel ready, and I think had I gotten married at that point I wouldn’t have been happy.

SEVERSON: Do you think there’s a downside to getting married too young?

LARSEN: Don’t ask me, because I married in my mid-30s, so I’m kind of like my own congregation.

SEVERSON: Bishop Fonz Allen has a congregation of 21-to-30-year-old singles. He says getting married young and struggling can be a good thing.

BISHOP FONZ ALLEN: Many of us in the earlier years, we got married while we were still going to school, and we had children while we still going to school, and we look back on those times today, now when we’re older, as the best times of our life, when we were struggling. So we don’t encourage people to wait to get married.

WILCOX: Folks who get married in their teens are more likely to get divorced, and that’s true across the board. It’s true for Mormons; it’s true for secular folks. People who get married in their mid-20s are pretty safe when it comes to the risk of divorce.

SEVERSON: Nationally, the divorce rate is down, from 50 to 43 percent. Among Mormons it’s about 20 percent. Church leaders say it’s because of the strong emphasis on family—one night is set aside each week for family home evenings—and also because of the church’s teachings on chastity.

LARSEN: In our faith we don’t allow for premarital sex, and I’m sure that does happen, but it’s a rarity, and we are teaching them to hang onto their values.

SEVERSON: Twenty-six- year-old Megan Baer recently got engaged. She says she’s glad she waited.

MEGAN BAER: We have sex drives just like everybody else, so of course it’s very hard, but I love what we call the law of chastity, which is no sex before marriage and complete fidelity when you’re in marriage, and I think it’s kept me from a lot of regret and pain.

SEVERSON: Professor Wilcox says 85 percent of Americans have sex before marriage.

WILCOX: Individuals who have more sexual partners prior to marriage are more likely to get divorced compared to those who do not. It’s something about forming a bond with someone that is then broken, and the way in which that may lead to a certain distrust of the opposite sex or a certain kind of loss of faith in relationships or in romance.

SEVERSON: Another reason for the low divorce rate is that Mormons usually try to date someone of their own faith. Some we spoke with said they had dated outside the church, but it hadn’t worked out. Others are like Steve.

ARCHIBALD: I do not date non-Mormons just because we’re pretty lucky in this area. The numbers are in our favor, speaking for us guys. In our congregation alone here today will have 300 individuals, and close to 200 of them will be women.

SEVERSON: After the church service, the search for a lifelong eternal mate continues in earnest. Bishop Larsen predicts that by the end of this year, at least 20 couples in his congregation of 200 will be engaged or married.

For Religion & Ethics NewsWeekly, I’m Lucky Severson in Crystal City, Virginia.

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