Office of Parish Outreach Ministries/Health Care Ministry

Ethical Decision Making at End-of-Life

Introduction: Because of the kinds and numbers of medical advances which have taken place in this century, the phenomenon known as "the medicalization of dying" has arisen in recent years The medicalization of death and other cultural factors contribute to the institutionalization of the terminally ill and the dying. Of the 2.2 million annual deaths in the United States, 80% occur in health care facilities. Technology makes these deaths more complex. In roughly 1.5 million cases, death is preceded by rather lengthy discussions about stopping or not starting some medical treatments. Medical technology, if not properly administered, can occasion an unnecessary prolongation of the dying process. Some physicians are under the impression that they are obliged "to do everything" for the dying Catholic patient. Some family members request health care providers to "do one more thing". Therefore, patients often go through the dying process hooked up to many devices which do not offer a reasonable hope of benefit and actually entail excessive burden to themselves or impose excessive expense on the family or the community. These Notes are written for both ordained and non-ordained pastoral ministers to provide guidance in the critical task of preparing people for end-of-life decisions. The Notes are part of a series on end-of-life issues in which the theological, sacramental and spiritual teaching of the Church is presented.

Encounter with Death

There are a number of fears which people experience when they come face to face with death. These include: fear of losing control, fear of losing human dignity, fear of becoming increasingly dependent, fear of intractable pain, fear of being forced to die before they are ready, fear of not being allowed to die when they are ready, fear about economic cost, fear of dying alone.

These fears affect the emotional well-being of the person and can impact the decision-making process. The opportunity for discussion of fears and concerns is essential.

In the past, healthcare professionals and family members often colluded to keep "bad news" about diagnosis and prognosis from patients. It is now recognized that patients deserve to hear the truth to the extent that they wish to receive information. Knowledge of the facts is necessary so that preparations for death can be made.

Misconceptions

Some misconceptions exist among Catholics regarding Church teaching on end-of-life. These misconceptions include:

. When faced with natural death, one must seek and accept all life-support measures.

. Once a life-saving technique has been started, it can never be shut off

. Should a dying person go into heart failure, Catholics may not refuse artificial resuscitation by means of Do Not Resuscitate (DNR) orders.

.Catholics may never refuse artificial nutrition and hydration, no matter what form it may take.

· Because pain is a fact of life and can be "offered up" for a religious purpose, good pain medication practices are not important.

It is essential for Catholic pastoral caregivers to recognize these misconceptions, to be able to articulate correct Church teaching and to assist Catholics to make decisions based on an integration of Church teaching and informed personal values.

Catholic Teaching

The principle of the sanctity of life is the foundation for ethical decision-making at the end-of-life. The principle has both a negative and a positive obligation.

The negative obligation of the principle requires that we neither harm nor destroy life. There is an absolute prohibition against killing, ourselves or another. Human life must be protected from the contemporary threats of euthanasia and physician-assisted suicide.

The positive obligation of the principle of the sanctity of life requires that we care for our health and our life. We have a duty to seek necessary and ordinary medical care. That does not mean that all available treatments or procedures must be used in all circumstances. Physical life does not have a absolute value in itself. It is a limited and finite good. There comes a time when life must be surrendered.

.It is Church teaching that we must never take the life of innocent persons\; it is not Catholic teaching that we must prevent their dying, if to do so would be futile or excessively burdensome.

.Treatments that are "extraordinary" or disproportionate may be refused.

Allowing to die is very different from taking life. The underlying illness is the cause of death when futile or excessively burdensome treatment is withdrawn or withheld.

·Catholic teaching calls us to recognize the limits of medical technology. DNR orders and decisions to forgo artificial nutrition and hydration in some situations of terminal illness can be morally acceptable options.

·Organ and tissue donation are consistent with Church teaching and can be considered a virtuous decision.

·Effective management of pain is strongly encouraged. Attempts should be made to avoid inducing unconsciousness.

A Public Voice

Proponents of physician-assisted suicide are disturbed when Catholics stand in civil objection to their position and they quote "the law which declares the separation of Church and State". It must be pointed out that there is no such law. This statement is rooted in a false understanding of the law which forbids the establishment of any religion.

Whenever Catholics speak out against projected legislation which can be detrimental to the common good, they are exercising their civil duty as citizens of the United States. They are not "imposing Catholic teaching" on their fellow citizens but exercising their legal right to articulate their objections to a law which they sincerely believe will be harmful to society as a whole.

The Decision Making Process

Patients may seek help from a pastoral minister in making a good and proper decision as to how they should proceed in evaluating the information given to them by healthcare professionals. This is particularly true for patients who have no relatives or friends who can assist them in the decision making process in difficult situations.

It is important that the minister be qualified to assist the person in determining a proper course of action. This will require familiarity with the Church’s teaching on medical ethics and some practical knowledge of techniques for decision-making. In regard to the former, the pastoral minister must have basic understanding of the information afforded in specific areas of the Ethical and Religious Directives for Catholic Health Services. (See last page of the Ministry Notes). This document provides solid information on ethical issues such as the difference between proportionate (ordinary) and disproportionate (extraordinary) means of preserving life.

A series of questions can be helpful in moving toward an informed decision:

·Does the patient and family have all the facts and do they understand the information they have received?

·What is the medical status and prognosis and what are the treatment options?

·What are the possible consequences of a particular treatment?

·Are there alternative course of action (e.g., palliative care and symptom relief)?

·What are the patient’s beliefs and values?

·What are the patient’s feelings about the present health situation and preferences in regard to medical care — what does the patient want?

·Is there a reasonable hope of benefit?

·What would be the burden(s) to the patient?

·Is the patient concerned about burdens to the family?

·Are there conflicts of opinion between patient and family or within the family

Practical Steps

·Be aware of personal feelings and concerns about death and dying and engage in a continuous process of learning about the issues.

·Promote parish education and formation about end-of-life issues and encourage a more comprehensive care of the dying ministry.

·Educate parishioners about the importance of advance care planning and the completion of health care proxies.

·Seek expert ethical advice if complex situations arise.

Ethical and Religious Directives

In 1995 the National Conference of Catholic Bishops published the Ethical and Religious Directives for Catholic Health Care Services* to reaffirm the ethical standards of behavior in health care and to provide authoritative guidance on certain moral issues that face Catholics today. Part Five of this document concerns Issues in Care for the Dying. This section has a general introduction to the topic which gives precise "faith content" and an overview of Christian values to be nourished and protected during the dying process. A series of ethical directives follow from the theory articulated in the introductory statements.

A few excerpts from the general Introduction:

·The Catholic health care ministry faces the reality of death with the confidence of faith. In the face of death, the Church witnesses to her belief that God has created each person for eternal life.

·What is hardest to face is the process of dying itself, especially the dependency, the helplessness and the pain that so often accompany terminal illness.

·Effective management of pain in all its forms is critical in the appropriate care of dying.

·We are not owners of our lives and hence do not have absolute power over life. We do have a duty to preserve our life but this is not absolute either. We may reject life-prolonging procedures that are insufficiently beneficial or excessively burdensome.

·There are two extremes to be avoided: on the one hand, an insistence on useless or burdensome technology even when a patient may legitimately wish to forgo it and, on the other hand, the withdrawal of technology with the intention of causing death

A few excerpts from the Directives:

·Persons in danger of death from illness, accident, advanced age, or similar condition should be provided with appropriate opportunities to prepare for death. They should be afforded whatever information is necessary to help them understand their condition and have the opportunity to discuss their condition with their family members and care providers.

·A person has a moral obligation to use ordinary or proportionate means of preserving his or her own life. 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 expense on the family or the community.

·A person may forgo extraordinary means of preserving life. Disproportionate means are those that in the patient’s judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or community.

·There should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient.

·The free and informed judgment made by a competent adult patient concerning the use or withdrawal of life-sustaining procedures should always be respected and normally complied with unless it is contrary to Catholic moral teaching.

·Patients should be kept as free of pain as possible so that they may die comfortably and with dignity, and in the place where they wish to die.

·Medicines capable of alleviating or suppressing pain may be given to a dying person, even if this therapy may indirectly shorten the person’s life so long as the intent is not to hasten death.

*Available from: United States Catholic Conference Publishing Services

3211 Fourth St. NE, Washington, DC 20017-1194.

These Ministry Notes were prepared by Rev. James O’Donohoe in collaboration with Kelly Dunn, Director, Office of Parish Outreach Ministries/Health Care Ministry. For information: 617-789-2457. January 2000

Copyright © 2004-2006 Archdiocese of Boston; all rights reserved