End-of-Life Choice, Palliative Care and Counseling

Dogma v Dignity

Potent Breakthrough in Canada

By Barbara Coombs Lee
1/23/2013

Last week the government of Quebec announced plans to recognize aid in dying as a legal and protected medical practice in the province. They promise a new law by this summer.

A tremendously exciting announcement, it reveals a seismic shift in the thinking of both medical and political leaders. I cannot overstate the magnitude and power of this shift, and fervently hope America’s medical associations and politicians soon follow suit.

Specifically, the government of Quebec intends to regulate aid in dying in spite of the federal crime of assisting a suicide. As in the U.S., federal laws generally supersede provincial ones, and most people assume laws against assisting a suicide prevent doctors from providing life-ending medication to qualified patients who ask.

Canada’s national spokespeople are irate because they, too, hold this assumption. They respond that Quebec cannot change Canada’s criminal code. Even now federal lawyers are defending the assisted-suicide law against a British Columbia judge’s ruling that it’s unconstitutional as applied to aid in dying. They say federal law defines the crime broadly and they must defend it because parliament has repeatedly rejected reform.

But Quebec disagrees, says it intends to proceed and will stand on firm legal ground when it does. The Quebec government is confident it has the authority to adopt law and policy to meet its citizens’ deep desire for more choices at the end of life. How is this possible?

It is possible because aid in dying is different from assisting suicide. It is as different as a surgery is from a stabbing. One is a crime and the other a careful medical practice. Governments outlaw stabbings, but that doesn’t prevent them from regulating surgeries.

Apparently in Canada’s separation of powers, the federal government defines and prosecutes crime, and the provinces oversee healthcare. Quebec health officials have simply adopted the common-sense view that easing the suffering of a dying patient and ensuring a peaceful and pain-free death is a medical matter, not a criminal one. And as such, it falls under the jurisdiction of the province to regulate the practice of medicine.

For well over a decade Compassion & Choices has argued vigorously for a change from the language of “suicide.” We urge that “Language Matters,” as we call on academics, public officials, journalists and headline writers to employ neutral, accurate words to refer to assisted death. Oregon’s experience informs much of the national dialogue, yet commentators notoriously deploy inflammatory suicide language in what should be neutral public forums. Assisting a suicide is a felony in Oregon; to call medical procedures under Oregon’s Death with Dignity Act “assisted suicide” falsely labels them a crime.

Assisting a suicide – to maliciously goad a mentally ill person to act on his self-destructive impulses – should be understood as a crime. Aid in dying – to mercifully respond to a rational dying person’s request to abbreviate his suffering –should be understood as medical practice. Repeatedly, anti-choice forces have won political contests by blurring this stark and monumental distinction. That tactic just lost its mojo in Quebec.

Here, finally, officials are no longer blind to the distinction between assisted suicide and aid in dying, and they embrace its concrete legal consequences. Here at last comes validation that we have not been merely picking at semantics. Different words evoke different circumstances and different conduct.

Don’t think the blinders fell suddenly. Exhaustive study and deliberation by prominent entities gradually, carefully, broadened the perspectives and changed the formal position of government.

Doctors took the first step. In 2006 the provincial medical association, the Collège des Médecins du Québec, embarked on three years of study in which it examined modern medicine and society, polled its members, and reflected on the results. The Collège’s refreshing and authoritative discussion paper, Physicians, Appropriate Care and the Debate on Euthanasia – A Reflection, came out in October 2009 and launched the serious dialogue now bearing fruit.

Quebec’s National Assembly responded by appointing an all-party select committee that held hearings and deliberated for two years. Last March it published a beautiful report of findings and recommendations. Its 178 pages are available in English and well worth the read.

Finally, the government appointed three expert lawyers to a judicial panel to make policy recommendations and propose steps to implementation. It is this report that lays out the legal rationale and explains how the Assembly and the Ministry of Health are to proceed. For French readers, the 400-page document is available here.

The lesson here is that lawyers and politicians go where doctors lead them. They want doctors to decide what constitutes ethical practice for the 21st century. Tradition-bound medical societies of the United States (notably the AMA) guard their historic dominance in the doctor/patient relationship and refuse to acknowledge changing public expectations. They resist measures that entrust to patients crucial decisions about their own lives and deaths. They have used and continue to use their enormous political power and vast treasure to obstruct sane policy on aid in dying.

Other, more progressive medical societies (notably the American Medical Women’s Association and the American Public Health Association) have embraced change and support both the use of accurate language and the option of aid in dying.

With this enlightened example to our north, perhaps American medicine cannot continue its obstructionism much longer.

Ashland Hospital Merger Runs Into Scrutiny

Mail Tribune
September 15, 2012

 

A patient’s right to choose whether to have an abortion or receive aid in dying are “important” issues to Ashland residents, Mayor John Stromberg said during Friday’s forum on a possible partnership between Ashland Community Hospital and Dignity Health.

Several of the nearly 100 people who attended forums Thursday and Friday expressed their concerns over Dignity Health’s stance against the Oregon Death with Dignity Act and banning direct abortions unless the mother’s life is at risk.

Stromberg said he thought Dignity Health’s presentation was well done.

“I thought they made a serious effort to be forthright and not dodge any of the tricky issues,” Stromberg said. “It’s a very important, big decision for us. We also have to consider that we’re in the position with a hospital (ACH) that is not stable, and something has to be done.”

Unreimbursed costs associated with treating Medicare and Medicaid patients, other unpaid medical bills and charity care contributed to a $2.5 million loss last fiscal year for ACH. The hospital also posted a $1.5 million loss on operations during the 2008-2009 fiscal year.

ACH Chief Executive Officer Mark Marchetti said a partnership would strengthen the hospital’s ability to compete with larger hospitals in Medford and increase revenue and patient services.

“We can help Ashland get back on its feet — not only survive, but thrive,” said Peggy Sanborn, Dignity Health’s vice president of partnership integration.

Sanborn said Dignity Health has identified ways to bring ACH into the black and increase its services.

Dignity Health and ACH have signed a memorandum of understanding to the potential merger, but a definitive agreement will have to be signed before anything is official.

Because the hospital operates under a long-term lease with the city of Ashland, the City Council will have a say in approving the partnership.

“The decision is going to be made by the council, and we’re all going to take part in diligent conversation before it’s made,” Stromberg said. “I am going to be prepared to vote, but I try not to express opinions ahead of time.”

The mayor only votes to break a tie.

“I heard it loud and clear,” said City Council member Carol Voisin. “Death with dignity and abortion are serious issues that the community thinks our hospital should be able to address and perform.”

Stromberg and Voisin were the only council members at either meeting, and Voisin attended both.

If a merger is formed between Dignity Health and ACH, its working physicians would not be able to prescribe patients who qualify under the Oregon Death with Dignity Act medication that induces death upon ingesting, said Carol Bayley, Dignity Health’s vice president for ethics and justice education. More

How the Catholic Church Misunderstands Death With Dignity

By Wendy Kaminer
The Atlantic
September 17, 2012

My father, a lifelong atheist, died at 91 in a Catholic hospice center. He received excellent, compassionate care from his nurses and from a doctor who willingly administered the morphine needed to ease his suffering — although, she advised, it would hasten his death. Did she violate the doctrine of a church actively opposing a Death with Dignity proposal now on the ballot in Massachusetts?

The medical team was administering palliative care, not assisting in a suicide. According to a Church spokeswoman, “You can have whatever level of morphine you need to control the pain, even if that level of treatment hastens death.” Palliative care is “legitimate,” even when it risks “shortening life,” Cardinal Sean O’Malley explains — so long as “the intent is not to hasten death, but only to ease the pain of a dying patient.”

I guess God knows the intent of every physician who administers pain medication to terminal patients, but law enforcement officials can’t be expected to know it. And sometimes, palliative care involves not just “the risk of shortening life” but the knowledge that it will shorten life. What if the only way to ease pain is to shorten life? More

Catholic Healthcare West Becomes Dignity Health

Expansion in Oregon Tests whether it’s a Distinction without a Difference

As I previously blogged, the Catholic hospital brand is no longer desirable in the marketplace for mergers and acquisitions of healthcare entities.

This realization led Catholic Healthcare West, the nation’s fifth largest healthcare conglomerate, to give up its status as a ministry of the Catholic Church. In doing so the corporation exempted itself from obedience to the Ethical and Religious Directives for Catholic Healthcare (ERDs) and released its secular hospitals from control by their local bishops. Local bishops and the ERDs still define permitted services in its 25 Catholic hospitals.

The corporation changed its name to Dignity Health, revamped its board of directors and replaced the ERDs with a “Statement of Common Values” to set the ethical framework and define permissible care. Though not entirely secular (the Values Statement still refers to employees as “the hands and heart of the ministry), Dignity is clearly not Catholic when it comes to reproductive health. The Common Values statement precludes abortion and in vitro fertilization, but is silent on tubal ligation and vasectomy.

When it comes to services at the end of life, Dignity does little to release patients from the chains of Catholic doctrine. The Statement pays lip service to patients’ rights to make medical decisions, execute advance directives and name surrogate-decision makers. Then it goes on to address the crux of the matter — withholding or withdrawing life-sustaining treatment, and allowing the legal choice of aid in dying.

At first glance Dignity Health’s policy on life-sustaining treatment may seem balanced and patient-centered:

There is no obligation to begin or continue treatment, even life-sustaining treatment, if from the patient’s perspective it is an excessive burden or offers no reasonable hope of benefit. Death is a sacred part of life’s journey; we will intentionally neither hasten nor delay it.

Let’s put aside the obvious absurdity that a whole hospital system would vow not to intentionally delay death! That’s their primary job, no? And I trust if I arrived at a Dignity Health facility, injured and bleeding, they would do everything in their power to delay my death!

It appears that in their haste to disavow any participation in an intended death, drafters of Common Values inadvertently applied the mantra of the Catholic hospice industry to an entire healthcare system, including emergency rooms and surgery suites. Perhaps they can fix that in the next edition.

Retaining Catholic Doctrine Around Intention

I have written at length about the Catholic Doctrine of Double Effect and the disservice it pays dying patients. It allows death to come only as an untended consequence of treatment to relieve pain and other symptoms and never as the intended purpose of an act or omission. Any act or omission intended to cause death is labeled “euthanasia” in the ERDs and strictly forbidden.

The ban on purposeful dying gags patients who might otherwise express a yearning to complete a prolonged dying process. It tempts doctors to hold back on opiates as pain and breathlessness escalate during active dying, because they fear being accused of intending the impending death and practicing euthanasia.

A host of alternatives for peaceful dying are considered ethical and legal in every state. They include discontinuation of treatments like renal dialysis, ventilation and feeding tubes, deactivation of implanted pacemakers and defibrillators, and provision of treatments like palliative sedation and drugs to prevent air hunger and ease the dying process during ventilator discontinuation.

Under Dignity Health’s restrictions regarding “intention” patients and their doctors are allowed these legal alternatives only if they disavow any purpose to abbreviate the period of suffering and advance the time of death. Patients must ask in code to be “relieved of the burden of cardiac pacing” instead of asking to stop the pacemaker so the heart will slow, because the patient wishes to die.

Test Case in Ashland, Oregon

Dignity Health’s expansion plans target Oregon and its first acquisition is the community hospital in the city of Ashland. Officials at Dignity and Ashland Community Hospital (ACH) are working out details of the acquisition, but the Ashland City Council must approve the deal, because it involves leasing public lands.

ACH CEO Mark Marchetti has said since ACH never provided aid in dying on its premises, its function in relation to the state’s Death with Dignity Act will not change. We’re not so sure, and believe the City Council and Ashland residents deserve some assurances.

It matters little whether hospitals allow patients to take life-ending medication on their premises, because people don’t choose to die in a hospital anyway. Wanting to die at home is one of the big motivators for people gaining eligibility for aid in dying in Oregon. But access does depend on a host of patient-provider interactions that precede a patient exercising their rights under the law. Catholic entities in Oregon forbid these interactions, and it’s important to ensure ACH will not start doing the same.

We have asked ACH officials to assure Ashland residents in writing that the institution resulting from negotiations between ACH and Dignity Health will:

  1. Retain a neutral stance toward aid in dying and will not penalize, discharge or reduce services for patients who gain eligibility for aid in dying;
  2. Do nothing to prevent, deter or punish employees who provide patients with information about accessing aid in dying under the Oregon Death with Dignity Act.
  3. Permit its staff and contracted physicians to answer patients’ questions about aid in dying and refer requesting patients to knowledgeable and supportive resources to pursue their request;
  4. Allow employed, contract physicians and physicians with hospital privileges to discuss aid in dying upon a patient’s request and fulfill duties such as medical history review, consultation and reporting required by the Death with Dignity Act on its hospital premises and medical offices.

This week, ACH responded positively — in writing — to our request for assurances. The Ashland City Council should put the ACH response on record and make their approval contingent on those promises. Only then can the residents of Ashland have confidence that Dignity Health’s involvement in their community will not deprive them of rights and privileges they have held for fifteen years.

The Demise of the Catholic Hospital Brand

It used to be Americans viewed Catholic hospitals and healthcare systems with universal respect and trust. They had no reason to do otherwise.

Founded in the nineteenth century by orders of nuns with a mission to care for the poor, Catholic hospitals grew and thrived in modern industrial medicine. Many became conglomerates and dominant sources of healthcare in cities and towns throughout the nation, especially in the Western United States. The trade association founded in 1915, the Catholic Health Association today represents 1200 Catholic health care sponsors, systems, facilities, and related organizations and services. Catholics and non-Catholics alike have considered Catholic Healthcare an unqualified good, delivering high quality medicine and serving their communities’ needs. It made little difference to most people whether their hospital was Jewish, Seventh Day Adventist, Episcopal or secular. Indeed, the image of selfless nuns running charitable institutions probably bestowed a brand advantage on the Catholic entities.

This is no longer the case.

A conservative theology and obsession with obedience have ruined the brand. Nowadays the phrase “Catholic hospital” is as likely to conjure images of unyielding bishops enforcing dogma on the irreligious as kindly nuns delivering succor to the suffering. Today most people realize that very few nuns actually run or work in Catholic hospitals. Knowledgeable people also know Catholic hospitals deliver no more charity care than their secular nonprofit counterparts.

Change came gradually, but high-profile power plays by the bishops recently pushed the brand onto a steep downward slide.

Activist Bishops

1. Two years ago Phoenix Bishop Thomas Olmsted excommunicated a prominent nun for allowing doctors to save a woman’s life by terminating her pregnancy. When the hospital stood by the decision not to let both mother and fetus die, Olmsted stripped the entire medical center of its Catholic affiliation. National commentators openly warned women with reproductive emergencies to avoid Catholic hospitals.

2. In February 2010 Bishop Robert Vasa revoked Catholic affiliation for St. Charles Medical Center in Bend, Oregon for providing tubal ligations in keeping with prevailing medical standards for the procedure.

3. The Catholic Health Association supported its member hospitals until the bishops extracted an admission that local bishops are the “authoritative interpreter” of permissible Catholic healthcare. The Association’s CEO publicly affirmed absolute power for local bishops to interpret the ERDs (Ethical and Religious Directives for Catholic Healthcare) and even to develop their own if they choose.

4. Last year a bishop in Spain declared the decision to remove food and water from a 90 year-old comatose woman an act of euthanasia. Describing the vegetative states as a chronic illness, he objected to laws allowing the family to follow what they knew to be her wishes.

5. Last June the US Conference of Catholic Bishops met in Seattle, reproached Compassion & Choices by name and denounced aid in dying as an end-of-life choice. Defying logic, the Conference asserted that adding a choice actually restricts choice and creates an illusion of freedom. More to the point of doctrinal enforcement, they called aid in dying “a grave offense against love of self” that breaks the bonds of love with God.

Blocked Expansion

Aggressive enforcement of dogma did not go unnoticed in communities where Catholic Hospitals sought to acquire or merge with secular ones. Entities resulting from unification with a Catholic hospital are always obligated to adhere to Catholic teaching and follow the bishops’ instructions for Catholic healthcare.

1. Two years ago the citizens of Sierra Vista, Arizona demonstrated for months against the proposed takeover of a secular hospital by a Catholic healthcare system, until hospital officials dropped the proposal.

2. Early this year the Attorney General and Governor of Kentucky blocked a bid by Catholic Health Initiatives to merge with publicly funded University Hospital.

Demands of the Marketplace

The enormous significance of these events became evident when Catholic Healthcare West, the fifth largest hospital conglomerate in the nation announced termination of its status as a ministry of the Catholic Church.

Renamed Dignity Healthcare, the 50 hospital system seeks to acquire additional hospitals and triple its size. The CEO readily admits that concerns about Catholic affiliation hampered his ability to grow. At the time he said the change to a nondenominational board would create “a tremendous opportunity that will help accelerate our growth.”

Oregon is the first state Dignity targets for expansion. In a subsequent blog I will examine what this means for end-of-life choice in the town of Ashland, where Dignity seeks to acquire the community hospital.

The clear meaning of Catholic Healthcare West’s transformation to Dignity Health is that “Catholic” is no longer a desirable brand in the marketplace for healthcare partnerships and medical services.

Truer but Fewer

Visiting Ireland in April, I chatted with a Catholic monk as he showed us architectural details of a medieval church. He bemoaned the drastic changes underway as the government wrests control of 95% of the nation’s public schools from the hierarchy of the Church. But he acknowledged the change is necessary as the church has become more conservative and the state more leery of its control. I ventured the opinion that the Vatican’s radical conservatism hardly seems a strategy for long-term growth. “That’s not the point,” he said. “Church leaders value those of ‘truer’ faith,” and they don’t mind that this retains fewer truly faithful adherents.

If the same principle holds for Catholic hospitals in the United States, Americans take heed. Institutions that retain their Catholic affiliation and continue to embrace their ministerial role may be those most entrenched in Catholic moral teaching. Bucking imperatives of the market, they may be most inclined to apply the Ethical and Religious Directives strictly and hew narrowly to services and healthcare decisions the local bishop deems consistent with church doctrine. You can affirm, with our Sectarian Healthcare Directive, that no facility’s dogma should override your end-of-life choices, and I encourage you to do so. Because without vigilance, patients and doctors may have less influence than the bishop over healthcare decisions made inside their hallowed walls.