End-of-Life Choice, Palliative Care and Counseling

Posts TaggedUnited States Council of Catholic Bishops

Hospitals Ordered To Follow End-Of-Life Care Wishes

Listen to Barbara Coombs Lee on NPR’s All Things Considered

Read a transcript of the story here >>

Bishop cuts ties to hospital over birth control

By JEFF BARNARD Associated Press Writer
Feb 16, 2010
GRANTS PASS, Ore. (AP) — The Catholic Church is ending its long-standing relationship with St. Charles Medical Center in Bend over a surgical birth-control technique.

Diocese of Baker Bishop Robert Vasa said Tuesday the church can no longer sponsor the hospital because it continues to offer tubal ligation, which leaves women unable to get pregnant and is specifically prohibited by church teachings. “Pregnancy itself is not a disease, even though in our culture we treat pregnancy as a disease,” Vasa said. “So this prevents the function of a properly functioning organ under the guise of health care.

“It would be misleading for me to allow St. Charles Bend to be acknowledged as Catholic in name while I am certain that some important tenets of the Ethical and Religious Directives are no longer being observed.” Catholic Mass will no longer be celebrated in the hospital chapel, and church property not needed by the hospital will be returned, Vasa said.

The name of the hospital remains St. Charles, and the decision does not apply to affiliated facilities in Redmond and Prineville, which never were tied to the church, Vasa added. The hospital does about 235 tubal ligations a year, and Vasa and the hospital had been in negotiations over the issue for a few years. They finally decided that neither could bend from their positions.

“We just felt we have been offering these procedures for decades and we have an obligation to the patients in our community to offer the procedures they need,” said James Diegel, president and CEO of Cascade Healthcare Community President, the hospital’s parent company. “This should have no impact on our operations or finances or anything. It’s just a severing of an historical relationship that has been in place for 90-plus years.

“The hospital was founded in 1918 by the Sisters of St. Joseph of Tipton, Ind., and the order’s last administrator retired in 1988, serving on the board until 2000. The hospital was taken over by a local nonprofit organization in the 1970s. The hospital would continue to look to church directives for guidance, Diegel added.

“This doesn’t change who we have been, who we are and who we will continue to be going forward,” Diegel said.

READ THE PRESS RELEASE HERE >>

How Many Days After I Told My Ex Girlfriend

Directive says food and water must be give How Many Days After I Told My Ex Girlfriend n to patients in persistent vegetative state

Chicago Tribune
By Judith Graham, Tribune reporter
February 8, 2010

If ever Carol Gaetjens becomes unconscious with no hope of awakening, even if she could live for years in that state, she says she wants her loved ones to discontinue all forms of artificial life support.

But now there’s a catch for this churchgoing Catholic woman. U.S. bishops have decided that it is not permissible to remove a feeding tube from someone who is unconscious but not dying, except in a few circumstances.

Erica Laethem of Resurrection Health Care talks with resident physician Harjyot Sandhu during the rounds at Intensive Care Unit of the St. Marys of Nazareth Hospital in Chicago. (Tribune photo by Zbigniew Bzdak / January 28, 2010)
Erica Laethem of Resurrection Health Care talks with resident physician Harjyot Sandhu during the rounds at Intensive Care Unit of the St. Mary's of Nazareth Hospital in Chicago. (Tribune photo by Zbigniew Bzdak / January 28, 2010)

People in a persistent vegetative state, the bishops say, must be given food and water indefinitely by natural or artificial means as long as they are otherwise healthy. The new directive, which is more definitive than previous church teachings, also appears to apply broadly to any patient with a chronic illness who has lost the ability to eat or drink, including victims of strokes and people with advanced dementia.

Catholic medical institutions – including 46 hospitals and 49 nursing homes in Illinois – are bound to honor the bishops’ directive, issued late last year, as they do church teachings on abortion and birth control. Officials are weighing how to interpret the guideline in various circumstances.

What happens, for example, if a patient’s advance directive, which expresses that individual’s end-of-life wishes, conflicts with a Catholic medical center’s religious obligations?

Gaetjens, 65, said she did not know of the bishops’ position until recently and finds it difficult to accept.

“It seems very authoritarian,” said the Evanston resident. “I believe people’s autonomy to make decisions about their own health care should be respected.”

The guideline addresses the cases of people like Terri Schiavo, a Catholic woman who lived in a persistent vegetative state for 15 years, without consciousness of her surroundings. In a case that inspired a national uproar, Schiavo died five years ago, after her husband won a court battle to have her feeding tube removed, over the objections of her parents.

The directive’s goal is to respect human life, but some bioethicists are skeptical.

“I think many (people) will have difficulty understanding how prolonging the life of someone in a persistent or permanent vegetative state respects the patient’s dignity,” said Dr. Joel Frader, head of academic pediatrics at Children’s Memorial Hospital in Chicago and professor of medical humanities at Northwestern University’s Feinberg School of Medicine.

Gaetjens, a hospice volunteer and instructor at Northwestern University, has thought long and hard about illness and the meaning of life after struggling with multiple sclerosis for 40 years.

She said she has told her sister and a close friend that she does not want “heroic measures” undertaken on her behalf at the end of life. But she acknowledged that she has not studied Catholic teachings on the subject or thought through all the implications of her position.

“My pleasure is in being part of the human race,” she said. “If that’s gone, if I can’t interact with other people, even if they could give me nutrition and keep me hydrated, I’m not interested in being preserved.”

Some experts are advising that a similar stance is no longer tenable for devout Catholics. Church members should steer away from advance directives that make blanket statements such as “I don’t want any tubes or lifesaving measures,” said the Rev. Tadeusz Pacholczyk, director of education for the National Catholic Bioethics Center in Philadelphia.

The church’s view is that giving food and water to a person through a feeding tube is not a medical intervention but basic care, akin to keeping the patient clean and turning him to prevent bedsores, Pacholczyk said.

Pope John Paul II articulated the principle in a 2004 speech, and the Congregation for the Doctrine of the Faith, an arm of the Vatican, expanded on it in a 2007 statement. The new guideline incorporates those positions in Directive 58 of the U.S. bishops’ Ethical and Religious Directives for Catholic Health Care Services.

There are several important exceptions. For one, if a person is actively dying of an underlying medical condition, such as advanced diabetes or cancer, inserting a feeding tube is not required.

“When a patient is drawing close to death from an underlying progressive and fatal condition, sometimes measures that provide artificial nutrition and hydration become excessively burdensome,” said Erica Laethem, a director of clinical ethics at Resurrection Health Care, Chicago’s largest Catholic health care system.

Some ethicists are interpreting that exception strictly. The Rev. William Grogan, a key health care adviser to Cardinal Francis George and an ethicist at Provena Health, based in Mokena, said death must be expected in no more than two weeks – about the time it would take someone deprived of food and water to die.

But Joseph Piccione, senior vice president of mission and ethics at OSF Health Care in Peoria, said that if a patient knows she is dying of, say, incurable metastasized ovarian cancer but is several months from death, she can decline to have a feeding tube inserted if she anticipates significant physical or emotional distress from doing so.

A second exception has to do with bodily discomfort. If infection develops repeatedly at the site of the feeding tube, for instance, artificial nutrition and hydration can be refused or discontinued, Catholic ethicists agree.

A third exception is allowed when inserting or maintaining a feeding tube becomes “excessively burdensome” for a patient. That would apply, for instance, if a person regurgitates the food and develops pneumonia when it enters the lungs, Grogan said.

Under traditional Catholic teachings, patients may refuse medical interventions when anticipated burdens outweigh potential benefits.

“Decisions are made case by case,” and that will continue, said Ron Hamel, senior director of ethics at the Catholic Health Association of the United States.

Of particular concern is whether Catholic medical centers will honor an advance directive stating broadly that a person does not want a feeding tube inserted.

Compassion & Choices, a group that supports the right of dying people to end their lives, suggested the potential for conflict is significant.

“Now, (Catholic) hospitals and nursing homes have no choice but to enforce Catholic doctrine universally over patient wishes,” the group’s president, Barbara Coombs Lee, wrote on her blog.

But most ethicists said they do not see a significant problem. Disagreements, they say, usually can be resolved by discussing people’s end-of-life concerns, such as fear of being abandoned, fear of living in pain or fear of becoming entirely dependent on others.

It is rare for people to be very specific about their wishes.

“I have never seen an advance directive that says, ‘If I am in a persistent vegetative state, I ask that you withdraw food and water,’” Laethem said.

“We will be very attentive to patients’ advance-care planning,” Piccione said.

That offers some solace to people like Jim Lindholm, 69, who is struggling with a recurrence of non- Hodgkin’s lymphoma and attends St. Nicholas Catholic Church in Evanston.

“If there is no hope of recovery for me, if I’ve lost my active mental life, I don’t see any reason to keep my body alive,” he said. “I would prefer to die a peaceful death.”

Lindholm speaks from deep personal experience. A dozen years ago, his father suffered a stroke and lost the ability to feed himself and speak for himself. Attempts to feed him by hand did not succeed. His advance directive was clear: no extraordinary measures.

The doctors offered a feeding tube; Lindholm’s mother said, “My husband wouldn’t want that,” so Lindholm’s dad died of lack of food and water.

Lindholm still struggles with it. Did his father really want to starve to death? If his mother had agreed to the feeding tube, how long might he have lived?

“We owe it to those who survive us to make it very, very clear what we mean by ‘do not resuscitate,’” Lindholm said.

Although medical institutions are legally bound to respect patients’ advance directives, exceptions exist for providers who object by reason of conscience or religious belief, said Charles Sabatino, head of the American Bar Association’s Commission on Law and Aging.

The bishops’ guidelines specify that “advance directives are to be followed, so long as they do not contradict Catholic teachings,” said John Haas, president of the National Catholic Bioethics Center. How those teachings will be interpreted has yet to be resolved.

jegraham@tribune.com

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Questions and answers about Directive 58

Q. What did the bishops actually say?

A. This quote from Directive 58 gives the gist: “In principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic and presumably irreversible conditions (e.g., the ‘persistent vegetative state’) who can reasonably be expected to live indefinitely if given such care. Medically assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be ‘excessively burdensome for the patient or (would) cause significant physical discomfort.’”

Q. Is this an entirely new position?

A. An earlier version of the directive, published in 2001, spoke of a “presumption” in favor of giving food and water to patients in a vegetative state; the new version speaks of an “obligation” to do so and appears to extend to patients with other chronic conditions. Precedent for the position comes from a 2004 statement from Pope John Paul II and a 2007 statement from an important advisory group at the Vatican.

Q. What inspired the change?

A. Church leaders oppose assisted suicide and euthanasia and wanted to affirm strongly that the lives of severely disabled people have value.

Q. Does it apply to Catholics only?

A. The guideline affects all patients who seek care at Catholic medical centers, regardless of their religion, said Stan Kedzior, director of mission integration at Alexian Brothers Health System.

Q. Who decides if a feeding tube is “excessively burdensome” and therefore not warranted?

A. That’s up to the patient, but it isn’t as simple as, “I don’t like it and I don’t want it.” There have to be discernible physical, emotional or financial hardships for the patient, according to Joseph Piccione of OSF Health Care. Those hardships must outweigh the potential benefits.

Q. Does this mean Catholics must pursue all medical interventions at the end of life?

A. “No. We mustn’t all die with tubes,” said John Haas of the National Catholic Bioethics Center. “The Catholic Church has never taken that position.” Church members may refuse interventions they deem excessively burdensome.

For instance, someone with advanced kidney failure is not obligated to pursue dialysis, said the Rev. William Grogan, a health care adviser to Cardinal Francis George. Someone who has lost the ability to breathe is not required to use a ventilator.

Read the story at its original site on the Chicago Tribune website.

Copyright © 2010, Chicago Tribune

Media Shine Light on New Mandate from Bishops

We have been spreading the word since the US Council of Catholic Bishops (USCCB) adopted new rules in November, obligating feeding tubes for permanently unconscious patients in Catholic healthcare facilities. David Dayen at firedoglake and Ann Neumann at otherspoon have reported the story. Now traditional media sources are picking up the story.

On December 20th, Charles Stanley of Atlanta’s Sunday Paper reported on the new directive, its potential conflict with patients’ stated wishes, and the potential legal conflicts.

In yesterday’s San Francisco Chronicle, Bob Egelko reports on the new mandate’s impact on Bay Area Catholic care facilities and the families who could face unexpected challenges in making decisions about care for a loved one.

The directive plunges the bishops into another health care controversy, on the heels of their lobbying for tight restrictions on abortion coverage in health legislation pending in Congress.

Catholic hospital officials say the November decree isn’t rigid and leaves room for accommodating patients’ wishes. But the bishops’ language appears to conflict with a hospital’s legal duty to follow a patient’s instructions to withdraw life support, as expressed in an advance written directive or by a close relative or friend who knows the patient’s intentions.

Courts have ordered hospitals to disconnect feeding tubes when an unconscious patient’s wishes were clearly established. The best-known case involved Terri Schiavo, the Florida woman who died in 2005 after 15 years in a coma and unsuccessful attempts by her parents and Republicans in Congress to keep her alive.

The bishops’ order “fails to respect settled law that empowers patients with the right to refuse or direct the withdrawal of life-prolonging care,” said Barbara Coombs Lee, president of Compassion & Choices, which advocates for the right of terminally ill patients to make life-or-death decisions.

“It will apply irrespective of your religious faith, your stated wishes in an advance directive, or the instructions of your family.”

That’s not how the bishops’ decree will be carried out, Catholic hospital organizations insist.

The decree itself does not require life-sustaining care that would be “excessively burdensome for the patient” or would cause “significant physical discomfort.” If those exemptions don’t apply, a hospital will send a patient elsewhere rather than violate his or her expressed wishes, the organizations said.

“If it was unresolvable … we would transfer them or find some other means to accommodate them,” said Lori Dangberg, spokeswoman for the Alliance of Catholic Health Care, which represents California’s 55 Catholic hospitals.

There you go. “the November decree isn’t rigid and leaves room for accommodating patients’ wishes.” Because you can do what the Bishops tell you to do, or go somewhere else.

You can read the full San Francisco Chronicle article here.

Catholic Hospitals Will Have to Comply with the Bishops Rules

Will Not Honor Conflicting Advanced Directives

On November 17, 2009, with little fanfare, the United States Conference of Catholic Bishops issued a directive for Catholic health care that could bring distress and grief to hundreds of thousands of American families each year. The directive is binding on all Catholic hospitals, hospices and nursing homes. It forbids removal of artificial food and hydration tubes from a patient in any Catholic health care setting, regardless of patients’ expressed wishes as contained in an Advance Directive or similar document. 

This directive limits your healthcare choices.

Questions have arisen about how a church hierarchy can abrogate legal directives from patients and whether Catholic health care providers will be required to follow church directives, whether patients are Catholic or not.

Below please find excerpts from some relevant directives:

Ethical and Religious Directives for Catholic Health Care Services (Emphasis added)

5. Catholic health care services must adopt these Directives as policy, require adherence to them with the institution as a condition for medical privileges and employment, and provide appropriate instruction regarding the Directives for administration, medical and nursing staff, and other personnel.

8. …the relevant requirements of canon law will be observed with regard to…

68. …must respect church teaching…

24. … The institution, however, will not honor an advance directive that is contrary to Catholic teaching.

28. … The free and informed health care decision of the person or the person’s surrogate is to be followed so long as it does not contradict Catholic principles.

59. … life-sustaining procedures should always be respected and normally complied with, unless it is contrary to Catholic moral teaching.

It appears that the Directives: (1) limit a patient from electing aggressive pain care, including terminal sedation-an accepted practice in medicine, ethics, and law; (2) result in the disregard of advance directives or decisions made by a health care proxy; and (3) result in the application of unwanted life support or the continuation of unwanted life support.

Read the Ethical and Religious Directives for Catholic Health Care Services here>>