discussion questions - honoring the dignity of life in...

Honoring the Dignity of Life in Sickness and Death

FR. J. DANIEL MINDLING, OFM CAP

End of Life Panel Discussion, St. Raphael’s Catholic Church, May 10, 2014

ARCHDIOCESE of WASHINGTONtransformfear.org #TransformFear

CHURCH TEACHING AND THE ETHICAL PRINCIPLES NEEDED TO MAKE SOUND MEDICAL DECISIONS

Quick FactsSTATISTICS:

v 50% of deaths in the US are due to heart disease and cancer v 29% of deaths in the US occur when 85 years and older

ABBREVIATIONS:

v ERD = Ethical and Religious Directives for Catholic Health Care Services, Fifth Edition, USCCB, 2009.

v PAS = Physician Assisted Suicide v DNR = Do Not Resuscitate v PVS = Persistent Vegetative State v MANH: Medically Assisted Nutrition and Hydration

KEY CONCEPTS AND DEFINITIONS:

v The Church guides us in our decisions based on:

o the unchangeable dignity of the patient,

o the concrete circumstances of the patient and the current state of health,

o and the benefit versus burden of a particular treatment to this specific patient.

v Decisions are never procedure specific; they are always patient specific.

v Advance Directives: legal documents through which individuals guide the course of their own medical treatment even after they can no longer make decisions or inform others of their desires (Maryland Bishops).

v Proportionate means are those that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expenses on the family and/or community (ERD’s, USCCB, no. 56).






Overview Continual advances in medical technology bring many blessings, but also pose complex ethical questions. When is it appropriate to take measures to prolong life? When is it appropriate to allow death to take its natural course? At the heart of Church teaching is the inviolable dignity of the human person. Thus, our decisions regarding medical treatments must be based on the dignity of the patient, the concrete circumstances of the patient and his/her state of health, and the benefit or burden of a particular treatment to the patient and his/her family. Decisions are never procedure specific; they are always patient specific. Whenever we are questioning which course of action to take, we should stop and ask ourselves if the treatment is futile or useful. Futile treatment has no benefit, while useful treatment is treatment that is effective and promises benefit. It is not necessarily a cure, but it helps. If the treatment is deemed useful, we have to then ask if it is proportionate. Proportionality is based on the appraisal of burden and benefit. If treatment is more burdensome than beneficial, it is deemed disproportionate. In such cases, the Church teaches that “when death is clearly imminent and inevitable, one can in conscience ‘refuse forms of treatment that would only secure a precarious and

burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted’” (Evangelium Vitae, 65). “Certainly there is a moral obligation to care for oneself and to allow oneself to be cared for, but this duty must take account of concrete circumstances. It needs to be determined whether the means of treatment available are objectively proportionate to the prospects for improvement. To forego extraordinary or

disproportionate means is not the equivalent of suicide or euthanasia; it rather expresses acceptance of the human condition in the face of death” (Ibid).

These same principles apply to questions regarding Medically Assisted Nutrition and Hydration (MANH). Generally, if death is not imminent, feeding the patient is presumable. If, however, death is imminent, then St. John Paul II’s teaching in Evangelium Vitae, 65, applies. When a patient is in a persistent vegetative state (PVS), we should generally provide artificial nutrition unless disproportionate means are ascertained. The same also applies for administering pain medication: nothing should be done to deliberately hasten a patient’s death. Pain medication given for the purpose of relieving pain is morally acceptable even if the dose needed may have an unintended side effect of hastening death.

Medical decisions are never procedure

specific; they are always patient specific.






Discussion Questions

v When should I accept or continue treatment?

v What if I don’t want to burden my family by prolonging treatment?

v What is the difference between assisted suicide and declining aggressive medical treatment?

v Does Church teaching require that I pursue every medical treatment possible to preserve life?

NOTES

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JOAN PANKE, MA, ACHPN, PALLIATIVE CARE NURSE PRACTITIONER



NAVIGATING SICKNESS AND DYING: WHAT HAPPENS TO THE BODY AS SOMEONE IS DYING?

Quick Facts

STATISTICS:

v 6% of deaths in the US are due to Alzheimer’s. This percentage has seen a dramatic increase over the last ten years and is expected to increase.

v Studies show that for some individuals, those who receive earlier access to palliative and hospice care experience improved symptom relief and may survive longer than those who do not have access to such care.

DEFINITIONS:

v “To palliate” means “to ease.” Palliative Care is specialized medical care for people with a serious illness at any age and any stage. It is focused on providing patients with relief from symptoms, pain, and stress of a serious illness, whatever the diagnosis. Its goal is to improve the quality of life for the patient and his or her family.

v Hospice provides palliative care for those in the last weeks or months of life.

v Non-‐hospice palliative care is appropriate at any point in a serious illness.

v Cachexia is the medical term referring to general physical wasting with unintentional loss of weight and muscle mass due to disease, as opposed to starvation. In progressive illness, cachexia usually indicates final stages and is rarely reversible with current treatments.






Overview

In order to help guide our decisions on how to best care for our loved ones, it is helpful to know the physical, psychological, and spiritual signs of approaching death:

PHYSICAL SIGNS:

Progressive weakness and fatigue

Function decline—bedbound; unable to feed or tend to basic needs

Lack of appetite

Cachexia

Constipation/diarrhea

Nausea/vomiting

Urine incontinence

Low blood pressure

Changes in breathing/not being able to get adequate breaths

Change in circulation: cooling of arms and legs

PSYCHOLOGICAL AND SPIRITUAL SIGNS:

Anxiety

Depression

Delirium

Agitation

Restlessness

Confusion

Coma

Change in sleep patterns

Hallucinations—visual, hearing

Talking about “going home,” or similar themes

Death Process: As other organs in the body begin to fail, the body focuses on three systems—the brain, heart, and lungs. Other organ systems are negatively effected by this change (for example: kidneys do not

work as well).







v What information is important to know about this illness, and what will likely happen to me/my loved one over time?

v What can I/we expect in the coming months, years, etc.?

v How do additional illnesses/conditions affect the different symptoms we might see?

v How will we know if/when we are entering into the final stages?

v What symptoms will I/my loved one likely have? Can anything be done for the symptoms we might see? Speak up about your concerns.

v Would any attempts at resuscitation be successful? If not – can you explain why?

v Is there a palliative care service available in my local hospital or community?

NOTES

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BURKE BALCH, JD, DIRECTOR, POWELL CENTER FOR MEDICAL ETHICS



MARYLAND LAW ON LIFE-‐SAVING MEDICAL TREATMENT

Quick Facts

ABBREVIATIONS:

v MOLST: Medical Orders for Life-‐Sustaining Treatment. This is a medical order (doctor’s order) relating to specific medical treatments. It applies to the patient’s current condition and is subject to updating.

KEY CONCEPTS AND DEFINITIONS:

v Advance Directive: Fixed medical guidelines given by the patient regarding future medical treatment.

v Four types of advance directives:

1) A written appointment of a healthcare agent (proxy)

2) A “living will”

3) An oral statement

4) The MOLST (Medical Orders on Life Sustaining Treatment)

v Proxy: A patient-‐assigned healthcare agent who will carry out the patient’s advance directive in the absence of the patient’s ability to do so. This should be someone you trust, such as a family member or close friend.






Overview

Illness and death are issues which many of us avoid until they are immediately confronting us. It is helpful to take time and prepare now so that when they inevitably come, we can face them with the comfort and peace of knowing how to proceed in light of Church teaching.

Once we have taken the time to discern our wishes, it is important to convey them in appropriate legal forms. This can be done by completing an advance directive, which allow us to guide the course of our own medical treatment when we can no longer make decisions. Maryland law recognizes four types of advance directives:

1) A written appointment of a healthcare agent 2) A “living will” 3) An oral statement 4) The MOLST (Medical Orders on Life Sustaining Treatment).

Appointing a healthcare agent (also called a “proxy” or “surrogate”) leaves decision making in the hands of a designated person with whom we have discussed our wishes. Since it is difficult to predict future medical conditions, it is preferable to appoint a prudent healthcare agent who will follow Church teaching and the guidance of the Holy Spirit in making decisions on our behalf.

Another form of an advance directive is what is called a living will, which authorizes the provision, withholding, or withdrawal of life-‐sustaining procedures if we are in a terminal condition and death is imminent, or if we are in a persistent vegetative state. From the Church’s perspective, because we cannot predict medical conditions, living wills pose a risk of directing what could in some cases be considered a morally inappropriate refusal or withdrawal of care. In most cases the written appointment of a healthcare agent is preferable to a living will because it names the agent, one we specifically choose, and empowers him or her to make decisions about life-‐sustaining procedures based on our actual condition, which may evolve over time.

Another option is the oral directive, which is an oral statement we give our physician. Usually an oral directive is given in the midst of a serious medical problem, or if we do not have a written directive. No one should make an oral directive without proper forethought and wise counsel. We should be careful to ensure that our physician and witness truly understand our wishes. In general, however, written directives appointing a responsible agent are preferable.






Overview Continued Finally there is the Medical Orders for Life-‐Sustaining Treatment (MOLST) form, which is a doctor’s order that governs a range of medical care options. Unlike an advance directive which is prepared when we are healthy, the MOLST is intended to be completed by our physician when we are seriously ill. Healthcare facilities are required to follow the orders set forth in the MOLST form, so this is a very important document.

SUMMARY:







v Am I legally required to have an advance directive?

v What happens if I don't have an advance directive?

v Why is appointing a healthcare agent important?

v What qualities should I consider in my healthcare agent?

v What kind of information should I include in my advance directive to assist my healthcare agent in making decisions on my behalf?

NOTES

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ETHICAL GUIDANCE FOR END OF LIFE CARE

Recommended Resources CHURCH TEACHING:

v Evangelium Vitae (The Gospel of Life): On the Value and Inviolability of Human Life, Pope John Paul 11, 1995;

v available at http://www.vatican.va/holy_father/john_paul_ii/encyclicals/documents/hf_jp-‐ii_enc_25031995_evangelium-‐vitae_en.html

v The Catechism of the Catholic Church

v United States Catholic Catechism for Young Adults

v “To Life Each Day With Dignity,” a Statement on Physician-‐Assisted Suicide, United States Conference of Catholic Bishops, June 16, 2011; available at http://www.usccb.org/issues-‐and-‐action/human-‐life-‐and-‐dignity/assisted-‐suicide/to-‐live-‐each-‐day/

v Ethical and Religious Directives for Catholic Health Care Services, 5th Edition, United States Conference of Catholic Bishops, November 17, 2009; available at http://www.usccb.org/issues-‐and-‐action/human-‐life-‐and-‐dignity/health-‐care/upload/Ethical-‐Religious-‐Directives-‐Catholic-‐Health-‐Care-‐Services-‐fifth-‐edition-‐2009.pdf

v “Vatican Declaration on Euthanasia,” Congregation for the Doctrine of the Faith, May 5, 1980; available at http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19800505_euthanasia_en.html.

v Congregation for the Doctrine of the Faith: “Responses to Certain Questions of the United States Conference of Catholic Bishops (USCCB) Concerning Artificial Nutrition and Hydration”

v Comfort and Consolation, Maryland Catholic Conference, September 2014; available at http://www.mdcathcon.org/





PALLIATIVE CARE RESOURCES:

v US Conference of Catholic Bishops. Ethical and Religious Directives for Catholic Health Care Services. Part Five: Issues in care for the seriously ill and dying. 2009; 29-‐33. Available at http://www.usccb.org/about/doctrine/ethical-and-religious-directives/, Directives: 55 – 61.

v Maryland Catholic Conference. Comfort and Consolation: Care of the sick and dying. Available at: http://www.mdcathcon.org/publications

v From Principles at the Heart of the Church’s Teachings:

5) No patient is obliged to accept or demand useless medical interventions (pg. 9-‐10)

6) There is no moral obligation to employ useful but excessively burdensome medical interventions; however, the meaning of “excessively burdensome” must be properly understood (pg. 10-‐11)

The Terminal Patient Near Death (pg. 20)

“Do Not Resuscitate” Directives (p. 22)

WEBSITES:

v www.getpalliativecare.org

Resources, information and links for planning for serious illness available at

v http://www.getpalliativecare.org/quick-facts/planning-for-serious-illness-advocating-for-loved-ones-2/

KEY RESOURCES:

v Clergy & Palliative Care providers!

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