Care of the dying: a Catholic perspective. Part II: Social and political context--Catholic providers must exemplify a caring community. Catholic Health Association

Fears of abandonment and isolation in an institution have increased the public demand for euthanasia and assisted suicide. To quell this movement, Catholic healthcare providers must provide a caring community where patients and care givers enable each other to confront the fear of death and find support in living with human limitation. To begin to address the social and political dimensions of issues about the end of life, Catholic healthcare providers must use clear and consistent definitions of the terms used to describe these issues, such as death with dignity, right to die, euthanasia, allowing to die, and assisted suicide. By acknowledging the influence of the media in forming attitudes and opinions, healthcare institutions can seize opportunities for public education on fundamental human and religious values. The first effort has to be directed toward educating members of the media. The Catholic Church supports the concept of advance directives, which provide an opportunity for people to express their values and the ways they would expect those values to be honored in decisions about medical treatment. Courts' role in resolving decisions about treatment should be limited. Patient self-determination is best exercised when a patient (or surrogate), in consultation with a physician, decides what is best. Catholic healthcare institutions should advocate for legislation that fosters an appropriate balance between protecting a patient's right to self-determination and the state's interests to protect life. At the same time, institutions' advocacy efforts should demand sufficient resources for holistic care for the dying.     

Care of the dying: a Catholic perspective. Part III: Clinical context--good palliative care eases the dying process. Catholic Health Association

In the midst of a push for legalized euthanasia and assisted suicide in the United States, the Catholic healing tradition should provide good palliative care and support for dying patients. Catholic healthcare institutions can have a counterinfluence on the euthanasia movement if they strive to relieve all forms of pain-physical, psychological, social, and spiritual. Care givers must adapt their pain management methods to diverse groups of patients and their needs. Comprehensive pain management includes not only specialized clinical programs to control physical pain, but also counseling and human support to minimize psychological pain, community support groups to counter social pain, and pastoral care resources to address spiritual pain. Truthful communication lies at the heart of the therapeutic relationship. Healthcare institutions can likewise organize themselves internally to offer optimal support programs for those who are dying, their families, and their care givers. Necessary ingredients for a comprehensive approach include integrated treatment plans, hospitable environments, policies on advance directives and collaborative decision making, ethics committees that are well versed in end-of-life issues, education programs, and a hospice philosophy of care.     

Care of the dying: a Catholic perspective. Part I, Cultural context: a CHA document challenges care givers to define appropriate care for the dying

In a society tempted to adopt legalized assisted suicide and euthanasia as appropriate responses to dying, the healthcare community is challenged to nurture positive attitudes toward death among all ages and to help those with terminal illnesses to live well while dying. Whereas family and friends were once the primary care givers, now members of the healthcare professions are. This shift has introduced tensions between medical professionals and patients, including their families, in defining appropriate behavior toward the dying. To enable the terminally ill to live well while dying, we need to allow them to retain as much control as possible within the limits of belonging to a community. Also, we need to secure their network of significant relationships so they can experience the affective bonds of trust and love that support personal dignity and enhance the meaning of life. Medical technology is to be used in service of the total good of the patient. This includes not only the relief or cure that therapy can bring, but also what the patient prefers, values about life, and regards as giving ultimate meaning to life. Catholic healthcare institutions are challenged to promote a sensitivity and respect for cultural diversity as they respond to the needs of the dying and those who care for them.     

A better approach to care of the dying. Catholic healthcare and the Catholic community can present an alternative to physician-assisted suicide

To combat physician-assisted suicide, Catholic healthcare and the Catholic community cannot solely focus on mounting campaigns and formulating policies. They must also demonstrate an alternative way to approach death and care of the dying, taking a leadership role in improving end-of-life care. To accomplish this, Catholic healthcare must foster a culture that recognizes death as the inevitable outcome of human life and makes care for the dying as important as care for those who may get well. The ministry must acknowledge the limits of human life, human abilities, human ingenuity, and medical technology; and respect decisions to forgo life-sustaining therapies. In addition, physicians must address advance directives with patients before hospitalization and must be willing to offer hospice care as an option to dying patients and their families. More effective pain management must be devised. Catholic facilities must develop palliative care policies and commit to ongoing education to provide such care. It is essential that they pay attention to the environment in which patients die; identify the physical, psychosocial, and spiritual needs of family members; and use prayer and rituals in meaningful ways. With a clear focus on improving end-of-life care, Catholic healthcare--in partnership with other denominations--can eliminate some of the factors that can make physician-assisted suicide seem appealing to suffering people.     

Catholic healthcare as "leaven". To penetrate and renew society, Catholic healthcare must meet five requirements

Pope Paul VI described the church as the "leaven" of civil society. Catholic healthcare should strive to be the leaven of U.S. healthcare. To achieve this, it must do five things: Immerse itself in civil society. Catholic healthcare professionals and organizations should participate in efforts to improve public health, even when they are not in full agreement with those efforts. Provide high-quality care. Such care is not always easy to define, but Catholic healthcare can and should set high objective standards for the well-being of its patients. Minister to the suffering and dying. The Catholic view of suffering and death as necessary for human fulfillment is a countercultural idea in our society. Catholic healthcare should, while eliminating physical pain when possible, help people to die in a holy atmosphere. Be a responsible, just employer. Catholic healthcare should treat employees as individuals worthy of respect, not as economic units. Be advocates for the poor. Catholic healthcare should not only provide charity care for the poor; it should also work for universal coverage, care based on need rather than on ability to pay for it.     

Character witness. Walking the talk on euthanasia

Our response to the euthanasia movement brings us to the depths of moral character and spirituality. Character bears witness to the true significance of our Catholic convictions about the dignity of persons, the value of life, our dependence on God, and our interdependence on one another. To be credible players in public debates on euthanasia and assisted suicide, we have to bear convincing witness, personally and corporately, to the ways we care first for ourselves and for those who are not as fortunate as we--the sick, the elderly, the indigent, and the dying. Who we will be in the face of death will have a lot to do with what we have come to believe about life, with the values we have upheld, with the attitudes we have taken, and with the habits of thought and behavior we have formed. So we need not be victims of what dying has in store for us. Rather, we can engage our dying by developing those habits of the heart which will make a difference in the way we adapt to unwanted circumstances and endure what we cannot change. We cannot develop strength of character if we are not nurtured by a community of character. In addition to personal character, we also need to be a community that gives witness to those fundamental religious and moral convictions which shape our living and dying in ways that would make euthanasia unthinkable.     

Healthcare and social responsibility. The revised directives clarify the Catholic position

The Catholic Church participates in the U.S. healthcare system by reason of its contribution to the common good of society. To facilitate this, the Ethical and Religious Directives for Catholic Health Care Services set forth certain normative principles. Catholic healthcare is dedicated to promoting human dignity and the sacredness of life; it has an "option for the poor"; it seeks the common good, cooperating with other providers toward that end; it prohibits abortion, in vitro fertilization, contraceptive sterilization, and assisted suicide procedures in free-standing Catholic healthcare institutions. This article focuses on the directives in Parts 1 and 6 of the ERD. Directive 2 calls for mutual respect among care givers. Directive 3 discusses ways to care for people "at the margins of society." Directive 4 describes the medical research permitted in Catholic facilities, and Directives 5 and 9 suggest how such facilities can best perpetuate their Catholic identity. Directive 7 mandates that Catholic facilities treat employees justly. Directive 8 says that such facilities must observe canon law in transferring sponsorship or in founding, closing, or selling an institution. Directive 68 suggests that the bishop be involved in a proposed partnership that may infringe upon Catholic identity. Directive 70 urges Catholic facilities to avoid scandal, and Directive 69 warns that some forms of cooperation are unethical even when scandal is not present.     

Does compassion include euthanasia? Physicians' roles in caring for the terminally ill preclude the use of euthanasia

As technological advances continue to allow physicians to prolong dying patients' lives, healthcare providers face many issues surrounding physician-assisted suicide and euthanasia. When a physician performs euthanasia or assists in suicide, he or she is killing the patient. The action can in no way be interpreted as allowing an eventually inevitable death to occur earlier rather than later. The physician is culpable. Physicians play three important roles when caring for terminally ill patients: adviser, friend, and priest. The risks inherent in each of these could create an illusion that performing euthanasia and assisting in suicide are humane and logical options. Finally, physicians should not miss opportunities for grace when caring for dying patients. When physicians convey the diagnosis, when patients express the desire to control the timing of the death, and when patients are feeling sadness and anger, physicians must rise to the occasion to act as friend and minister and to introduce grace and healing to the dying.     

Issues at the end of life. The revised Ethical and Religious Directives discuss suicide, euthanasia, and end-of-life procedures

Part 5 of the Ethical and Religious Directives for Catholic Health Care Services reminds us that death is necessary for the transition to eternal life. Thus, although Christians have a duty to preserve worldly life, a gift from God, that duty is not absolute. Suicide and euthanasia are never morally acceptable. On the other hand, life-prolonging therapy need not be used if it provides insufficient benefit or imposes an excessive burden. Directive 55 describes the comfort and care that should be given to dying patients. Directives 56 through 59 discuss the ethical norms for either using or forgoing procedures designed to prolong life. Directive 60 repeats the Church's teaching in regard to euthanasia and physician-assisted suicide (PAS)--that is, whatever the intentions of those who employ them, euthanasia and PAS remain forms of murder. Directive 62 considers the methods used to determine that death has occurred. Directive 66 encourages patients to donate their organs and bodily tissue after death. However, the directive says, Catholic healthcare facilities should not make use of tissue obtained by direct abortions.     

Tradition in transition. What it means to be a Catholic healthcare facility today

Until recently we rarely questioned whether Catholic healthcare facilities would remain Catholic. New types of business ventures, however, have changed this. More important, the traditional elements that identified a facility as Catholic no longer seem enough to sustain the ministry. What are the distinct qualities that identify a healthcare facility as Catholic? Three elements are crucial to successfully defining any identity: distinctiveness, relatedness, and richness. To determine the meaning of Catholic identity, we must look at these elements from the perspective of the changes occurring in the Catholic Church and in healthcare in the United States. In light of this we can identify distinctive features that characterize U.S. Catholic healthcare. These components include understanding healthcare as a ministry, being guided by Church teachings, collaborating with others, participating in care for the world community and the poor, giving holistic care, promoting self-determination, and respecting and protecting human life while accepting suffering and death. Only in their totality, however, can these components set forth a vision rooted in our past that speaks to the realities of the present and calls us forward to a future where greater justice will reign.     

Terminal sedation: consultation with a second physician as is the case in euthanasia and assisted suicide

In terminally-ill patients in the Netherlands deep sedation by means of a continuous subcutaneous infusion with midazolam occurs more frequently than euthanasia and assisted suicide. Deep terminal sedation is applied to relieve symptoms during the phase of dying, but in contrast to euthanasia and assisted suicide, does not hasten death. In three terminally-ill patients, a 65-year-old man suffering from pulmonary carcinoma, a 94-year-old woman with general malaise, nausea and anorexia, and a 79-year-old woman in the final stage of ovarian carcinoma, a general-practitioner advisor was consulted about an end-of-life decision--deep terminal sedation versus euthanasia or assisted suicide. The first two patients were given deep sedation until death, in both cases a day and a half later. The third patient's request for euthanasia was considered to meet the legal criteria for euthanasia. Compliance with the Dutch statutory criteria for due care in euthanasia and assisted suicide might also be helpful when deciding about terminal deep sedation, but the role and responsibility of the attending physician may differ. However, the radical effects of sedation on the terminally-ill patient and the rapid changes in the clinical situation of the patient when the decision to sedate is taken, both emphasize the need for consultation with another physician.     

Mercy: an insufficient motive for euthanasia. Catholic ethical tradition requires that we temper our motives with reason and care before acting

Some experts argue that acts of assisted suicide and euthanasia are ethically appropriate because they are merciful. Compelling though it is, this argument is not sufficient for determining the morality of these acts. The ethical tradition that calls for mercy has never suggested that mercy is, by itself, a sufficient criterion for determining an act's moral appropriateness. Human motives are rarely, if ever, pure and objective. For that reason, our ethical tradition has insisted on tempering motives with reason and care. The criteria for determining when it is merciful to assist in another's suicide or engage in an act of euthanasia are, for all practical purposes, impossible to define. Commonly writers refer to a person's hopeless condition to justify the merciful response of assisted suicide or euthanasia. But unless we can agree on whether hopelessness is an objective or subjective reality, and until the criteria to define this reality are evident, it is difficult to see how assisted suicide or euthanasia can be a careful and reasoned expression of mercy. Only by examining one's intention can one judge whether an act that may appear to be merciful in a hopeless situation is appropriate. "Intention" refers to the reasoned decision or judgment one makes about a goal and the means used to achieve that goal. Even if we cannot control our emotional response (our motives) in a particular situation, we can control our judgment (our intentions). Within our moral tradition, we can be sure we are being merciful in a careful and reasoned way when we intend to protect and promote the good of life.(ABSTRACT TRUNCATED AT 250 WORDS)     

Making mission possible. A response to Rev. Richard A. McCormick's article on the preservation of Catholic hospitals

In "The Catholic Hospital Today: Mission Impossible?" (Origins, March 16, 1995, pp. 648-653), Rev. Richard A. McCormick, SJ, STD, questions whether Catholic hospitals can continue their missions in a society with so many factors and influences that seem to oppose efforts to perpetuate the healing ministry of Christ. As Fr. McCormick states, the matrix of good medicine is centered on the good of the individual. But too often, the patient has been considered an individual isolated from others. The rights of families, people who belong to the same insurance program, and the society funding much of healthcare must also be considered. Fr. McCormick points out that an obstacle to the healing mission arises because healthcare is often treated as a business instead of a service. If not-for-profit healthcare facilities come to exist for the well-being of the shareholders, as do for-profit healthcare facilities, then a perversion of values results. This should lead us to renounce for-profit healthcare and the behavior that some Catholic health organizations have borrowed from the for-profit sector. In addition, Fr. McCormick calls attention to our society's denial of death and tendency to call on medicine to cure personal, social, or economic problems. This denial-of-death phenomenon helps us realize the need for the mission of Catholic hospitals. Continuing the mission of Catholic hospitals will require the attention of all involved in them-physicians, trustees, nurses, administrators, and ancillary personnel. These healthcare providers must not be distracted from the mission by joint ventures and economic issues.     

American culture and euthanasia. The changing definition of a "good death"

Divisions run deep in contemporary America over the issue of assisted suicide or mercy killing. The active, directly intended, and freely chosen self-destruction that was once unspeakable has become speakable. A recent best-seller providing "how-to" information on suicide; Initiative 119 in Washington State, which would allow "aid-in-dying"; and other publications and polls indicate that the proponents of mercy killing may have won over American culture, or at least established a dominant foothold. One of the chief criticisms of policies that permit mercy killing and assisted suicide is that they inevitably encourage suicide among those who are neither terminally ill nor suffering from physical pain. American culture is extreme in its desire to eliminate suffering. In a culture that can no longer depend on religious insights into human suffering, all kinds of preemptive strikes against suffering seem inevitable. The success of proponents of euthanasia is an indirect indictment of a healthcare system that fails to provide good palliative care and support. In our curative and rescue-oriented healthcare system, management of pain is not a priority. And our society also undervalues caring in its most basic sense. It is not so much death as the absence of caring and the denial of reality that may be the enemy. The desire to control pain has always been valid, but not the desire to press control so far as to directly cause death itself. Death by lethal injection is best understood as a tyranny of technological control.(ABSTRACT TRUNCATED AT 250 WORDS)     

Persistence and pain. Women and healing in the Gospel offer insights to Catholic healthcare providers

Scripture can enlighten us on the difficult times Catholic healthcare providers face today. Two stories from Mark's Gospel offer helpful insights to persons engaged in the institutional context of healing. These stories are of the woman with the "flow of blood" (Mk 5:25-34) and of the Syro-Phoenician woman (Mk 7:24-30). The women were determined to receive the healing they needed. They went for it, and got it, despite considerable obstacles. I suggest five insights we might draw from these two narratives of healing. These women were persistent. Sometimes it takes a great deal of persistence to find God in all the ordinariness, the numbing everydayness we encounter in our daily work. Like these women, the healing you seek for those you care for takes place in a hostile world. Catholic healthcare institutions themselves face some hostility from other institutions. The stories remind us that we must feel our own pain and that of others. The capacity to hurt and to feel the hurt of others helps us persevere in the face of this hostile world. Both women did what others could--and should--have done for them. Each of these women found in herself a place of strength she could draw on. This place of strength is the presence of God. I hope that Catholic healthcare providers are aware of God's presence in them and in those to whom they minister. I hope they work against the "quick-fix" mentality of much of modern healthcare and modern consumerism. Catholic healthcare recognizes the sacramentality of life on earth, struggling always to find the God who is revealed where we least expect her.     

An educational response to assisted suicide. Catholic systems reach out to advance compassionate care of the dying

The future of "The Oregon Death with Dignity Act" is uncertain since a preliminary injunction blocking the law's enactment has been granted. Still, three Catholic healthcare systems in the Pacific Northwest are quite clear about their commitment to providing optimal care to persons at the end of life. Bellevue, WA-based PeaceHealth; Seattle-based Sisters of Providence Health System; and Aston, PA-based Franciscan Health System have formed the Committee on Care of the Dying of the Franciscan, PeaceHealth, and Providence Health Systems. The three organizations have collaborated to develop and offer comprehensive educational outreach on compassionate care of the dying throughout Oregon. Twenty system representatives met in Portland, OR, in January 1995 and developed a vision statement, "Care at the End of Life." In addition, a steering committee of 12 representatives has identified the goals of the Committee on Care of the Dying. The steering committee has also identified seven "Organizational Commitments and Common Elements" to ensure quality and excellence in compassionate care of the dying. Recently, the Daughters of Charity National Health System, the Carondelet Health System, and the Catholic Health Association-all based in St. Louis-have joined this collaborative effort to educate healthcare providers and the public.     

Working for the common good. Catholic healthcare's opportunity to shape values-based managed care

Managed care has come under fire lately, and states and the federal government have stepped in to regulate some plans' deficiencies. Some say regulation is not enough; managed care is morally flawed. But the evils of managed care are the result of letting it be shaped solely by market-driven forces rather than mission-driven values. In the Catholic tradition, healthcare is part of the common good. Viewed in this light, managed care becomes more than just a way to control costs. For managed care to serve the common good, we will have to collaborate with other providers that demonstrate a commitment to human life and dignity that is similar to our own. Such collaborations may force us to negotiate (without compromising) our values, but this gives us the opportunity to recognize a hierarchy of goods to be pursued and evils to be avoided. Through our involvement in managed care, we can help shape the greater culture, as well as the culture of healthcare. But we must prioritize our commitments according to values and principles grounded in the Catholic moral tradition. Without these values to guide us, Catholic healthcare will lose its identity and fade away.     

Healthy communities: good mission, good sense. Holistic approach is the key

Catholic healthcare's mission is keeping people healthy, and providers must listen closely to determine their needs in these fast-paced, stressful times. In a society preoccupied with technology and acute care, which has the least overall impact on people's health, providers must implement more preventive strategies. The shift to promoting community health will require diverse, creative approaches. Catholic facilities must offer holistic healing, becoming community resources for children and the elderly. Religious institutes also must prepare for the laity's increasing role in the ministry. Providers must develop initiatives that define Catholic healthcare, such as the Welfare-to-Work Program in St. Louis, which offers women employment opportunities and benefits as a starting point to gain control of their lives. With increased school collaboration, nurses can help children develop good health habits. The guiding vision must be the health of the whole person and the community. Catholic providers must restore public trust and confidence by emphasizing person-centered healthcare. Only by becoming an integral part of the community can Catholic healthcare make a difference in people's lives.     

Educational needs of healthcare professionals and members of the general public in Alberta Canada, 2 years after the implementation of medical assistance in dying

Medical assistance in dying (MAID) was implemented across Canada in June of 2016, after each Canadian province and territory had developed their own MAID processes. Over the first 2 years, just under 300 Alberta citizens received MAID services, a very small proportion (<0.5%) of all 52,000 decedents. An online 2017–2018 survey of Alberta healthcare providers and members of the general public was conducted to assess and compare their knowledge of MAID. A devised brief survey tool was posted online, with broad‐based advertising for voluntary participants. The survey was taken down after 282 Albertans had participated (100+ healthcare professionals and 100+ members of the general public), a non‐representative sample. Through SPSS data analysis, educational needs were clearly evident as only 30.5% knew the correct approximate number of MAID deaths to date, 33.0% correctly identified the point in life when MAID can be done, 48.9% correctly identified the locations where MAID can be performed, 49.3% correctly identified who can stop MAID from being carried out, and 52.8% correctly identified how MAID is performed to end life. Healthcare professionals were significantly more often correct; as were participants born in Canada, university degree holders, working persons, those who identified a religion, had experience with death and dying care, had direct prior experience with death hastening, thought adults had a right to request and receive MAID, had past experience with animal euthanasia, and had hospice/palliative education or work experience. Age, gender, and having previously worked or lived in a country where assisted suicide or euthanasia was performed were not significant for educational needs. These findings indicate new approaches to meet sudden assisted suicide educational needs are needed.     

A new role for the Church. Dioceses should do more in providing care for dependent and dying persons

In 1988, with the publication of Catholic Health Ministry: A New Vision for a New Century, the Commission on Catholic Health Care Ministry called on the Church to redefine its healing mission in society. Unfortunately, despite various efforts, the Church has not yet fully articulated a shared vision of Catholic healthcare, healing, and support. Healing human brokenness has always been the Church's work in the world, whether the brokenness be physical, emotional, intellectual, moral, or spiritual. The Church, having a broader definition of brokenness than that of the larger healthcare system, must sometimes act as a countercultural critic of that system. Two of the great challenges facing healthcare today are providing care for dependent persons (people with chronic illnesses and older people) and for dying persons. In both cases, much more coordination of the various actors is needed. The Church could ensure that this coordination is carried out. In each diocese, the bishop should organize a pastoral health and social service planning group to assess community needs and apply Church resources to them. Local Catholic healthcare providers and social service agencies should develop a corporate culture of healing and support. Parishes should accept the idea that healing and supporting frail people are integral parts of parish life.