Betty had served God well for years as a missionary in Africa. She was a strong believer and had a passion for the glory of God. At 80 she began to lose things and had difficulty remembering recent events. By 83 she was no longer able to care for her invalid husband and was placed in a nursing home. For the last five years of her life she sat and babbled incoherently. She would seem to recognize her family, but could not carry on an intelligent conversation with them. She no longer recognized me as her doctor, but would call me "pastor." I liked that. She ate well, but was not able to control any other body function. She slept very little. One day she suddenly collapsed and died.

We look on the end of Betty's life as a tragedy. Indeed, from a human point of view, it was. Her care was expensive. It was not obvious that she made any contribution to her society. Some would say that her life was meaningless. Euthanasia may be proposed as a solution. How do we as Christians respond? I would like to share with you some of the perspectives I have on dementia. Please note that I am lumping multiple diagnoses, including Alzheimer's, into this discussion of dementia. Most of my comments are relevant independent of the underlying etiology.

One: Dementia is a disease

Like all disease, dementia is ultimately the result of the fall into sin recorded in Genesis 3. It was not part of God's original creation when He said, "It is good." Like all of the consequences of the fall, it will one day be corrected for believers as a part of the redemption that we have in Christ. We rarely see dementia resolved in this life, but we will see such a resolution in eternity.

Two: The demented are made in God's image

We err when we confuse the fact that we are humans made in God's image with our intellects. Nevertheless, we do it all the time. How easy is it for me to think that I have value because I am smart, I did well in school, or I am a doctor. No, the fact that I am made in God's image is totally different from my intellect and imparts me with a value that supersedes any ability or skill that I have. The demented have just as much value as anyone else because they are also made in the image of God. Genesis 9:5-6 assures us that being made in the image of God is a protection for that life. Therefore euthanasia is not an option for a Christian.

Three: Early dementia may bring increased spiritual sensitivity

There are many who go through life with attitudes of self-sufficiency. We have all heard, "No I do not want any help. I am quite capable of doing it myself. Thank you." Not infrequently persons who say such things have said the same to God and to His offer of redemption in Christ. Dementia knocks and it becomes obvious that we are not that independent. All of a sudden we are confronted with the fact that we cannot do everything by ourselves and we must lean on others. This is a wonderful time for the Gospel to be lovingly presented. It may receive a different reception than it has received before.

Four: Later stages of dementia afford unique opportunities to serve

Our Lord Jesus said: "If you love those who love you, what credit is that to you? Even 'sinners' love those who love them. And if you do good to those who are good to you, what credit is that to you? Even 'sinners' do that" (Luke 6:32-33).

Showing love to those who cannot return the favor is particularly relevant to the demented. It is an impressively valid way for believers to demonstrate the love of the Heavenly Father to a world that needs to see it. Those who are caring for the demented are doing exactly what our Lord commanded. It is never easy. There are several things in particular that make it challenging:

• The demented can be uncharacteristically focused on themselves. In this way they may be like a child. Godly, giving, and loving people can suddenly become very self-centered. This can be difficult at family gatherings because the person with early dementia may expect all of the discussion to revolve around them.
• The demented patient can be very gracious to outsiders or to more distant loved ones but very hard on the one they depend on the most. This frequently creates family turmoil between the siblings who are involved in daily care and conflict with those who are less involved.
• There is much day-to-day vacillation in the ability to function. It becomes increasingly difficult to be social or to perform the activities of daily living. Some days the energy is there and some days it is not. The parent may rally the needed strength when the son visits from the next state, but may not do it for the daughter who lives in the duplex next door. This contributes to the sibling turmoil that is stirred by the demented parent.
• The demented may make totally unrealistic demands on others and be irresponsible in the way they handle their financial affairs. It is helpful to have a power or attorney appointed for all legal matters (not just healthcare) very early in the process of dementia. One of the challenges is how to "honor our parents" in the context of dementia. It is clear from the rabbinic teaching related to the Old Testament that this commandment had particular reference to providing for the financial needs of our parents. Yet the New Testament puts this in larger context. It may be that honoring them means treating them in the same way we would want to be treated ourselves when we are similarly demented, while not necessarily doing everything they want.

As we relate to the demented believer it is good to reach out and touch their spiritual lives. I have found several things helpful in this context. Start reciting a verse of Scripture in the translation that the patient memorized and see if they can finish it. Do the same with an old hymn. Communion may be very meaningful to the demented. It may also help to give them short phrases from Scripture to repeat over and over again. The struggling saints of earlier eras would continuously recite the "Jesus prayer," "Lord Jesus Christ have mercy on me."

Five: Dementia is a progressive, terminal illness

Guidelines for the application of life-sustaining technology are not necessarily different for one who has progressive dementia than for one with a slowly progressing cancer. At some point it is appropriate to pursue palliative care. Hospice may be appropriate. It may not be necessary to aggressively intervene in the context of overwhelming infection or cardiac arrest.

The question of feeding tubes is always the most difficult. The natural end of stage three Alzheimer's is to stop eating. I believe that, consistent with our Lord's commands, we should offer food, using whatever conveyance possible to help them eat and drink. It may be pureed; it may be administered via straw or syringe.

Nevertheless, because we are dealing with a progressive terminal disease, I do not feel that we are obligated to use any invasive technology like a feeding tube. At the same time I feel this is not my decision and am happy to order a feeding tube when it is desired.

We would affirm that God is sovereign. He does not allow anything to come into our lives that is not subject to redemption. Dementia is in His sovereign control. Though it is a result of living in a fallen world, God can still redeem it and accomplish His glory.