Decisions of Life & Death Webinar - Notes

Professor Steve Bozza & Dr. Matthew Bunson

I.                    Asking the right questions is so important!

• For example: Is mom in the state of “medical futility”?

• Futility tells us that there is nothing more that any physician can do to stop the inevitable – death.

• We cannot accept the response that “Well, we can make a case for it” because you can make a case for anything and we do not want to do that.

• We want to know the FACTS – the CLINICAL FACTS – YES OR NO.

• If there is something else that can, in fact, be done, then we have other assessments to make.

II.                 We must be FORWARD THINKERS and educate ourselves. Here are two resources:

• OSV (Our Sunday Visitor) puts out an excellent pamphlet by Professor Steve Bozza called “Frequently Asked Questions – End of Life Issues.” See links below:

  - https://www.orderosv.com/product/frequently-asked-questions-end-of-life-issues-2

  - https://resources.osv.com/catalog/PDFs/P1772.pdf

•  National Catholic Bioethics Center (https://www.ncbcenter.org/) You can call them for a phone consultation. They will provide you with the authentically Catholic position.

III.               “Quality of Life” – Stay away from that term. The issue of quality of life is extremely subjective.  For example, my quality of life may be different from your quality of life.

It might be better to talk about “Human Flourishing.” Is this person going to flourish? Will they be able to live what is normal for that person?

Death is a part of life but it is not something that we should be causing.

The “contraception mentality” has led to a “Devolution of Ethics” because if we believe we should be allowed to determine when life begins, then it is only a matter of time before we believe that we should also be able to determine when it ends.

IV.              Pope Pius XII: “Life, health, all temporal activities, are, in fact, subordinated to spiritual ends.”

This leads into “Redemptive Suffering”:

• In terms of a person’s health, we can do the best we can to alleviate pain and we ought to; it is inhumane not to.

• But, at the same time, we are not going to be able to get rid of all of it.

• As Catholics we are very fortunate to have the revelation of Redemptive Suffering - meaning that we can join our sufferings to the sufferings of Christ.

• Ways that our suffering can be redemptive:

  1. It is redemptive for the SUFFERER (can lead to repentance, offering suffering as a penance for past sins, etc.)

  2. It is also redemptive for those watching the sufferer (it can unleash a deeper love and compassion in their hearts. This could be their ticket to heaven or, without this opportunity, to hell.) In God’s plan, suffering is meant to be purifying for everyone involved.

  3. It is up to us to use our free will to bring ourselves to a place of repentance, forgiveness, penance, etc.

  4. When we decide “I don’t want to suffer,” we rob ourselves or our loved one of the process of reflection on how life has been lived and seeing the things that need to be corrected in order to enter into eternal life.

  5. Read Salvifici Doloris – On the Christian Meaning of Human Suffering by Pope St. John Paul II (http://www.vatican.va/content/john-paul-ii/en/apost_letters/1984/documents/hf_jp-ii_apl_11021984_salvifici-doloris.html ) to learn more about redemptive suffering.

V.                 Guiding Principles VS. Blanket Statements

• RESUSCITATION – For examples: Should paddles be used?

  The Benefits & Burdens need to be assessed.

  Example: Does this person have weak bones (many elderly people do). Will this crush his/her bones.

•  Proportionate vs. Disproportionate Care

 Disproportionate – means that this action doesn’t offer reasonable hope of benefit; or, the burdens are going to be more pronounced than the benefits. If the burdens are becoming too great for a person, you do not need to go there. If there are more benefits than burdens, we ought to consider it.

•  OBLIGATORY VS. OPTIONAL MEDICAL CARE/MEANS

  Ordinary Care:

  • Something done almost routinely

  • Not experimental

  • Not burdensome

    Extraordinary Care (not obligated to do):

• Experimental

• Not offering reasonable hope of benefit.

• Is basically disproportionate to a person’s care.

• DNR, DNI

  What are these terms and what should we, as Catholics, look out for when doctors are suggesting them?

  We have to look at the actual facility (place where healthcare is being received) because at times the facility might take upon itself to change the definition of what these terms mean.

  • DNR – Do not resuscitate This has everything to do with cardio pulmonary resuscitation (for example: the paddles or whatever else the person needs to start breathing again and/or have cognitive abilities. Some facilities are construing DNR’s to mean “do not give certain types of medication.” They wrongfully have levels such as DNR 1, DNR 2, DNR 3. THAT IS BALONEY!

    A DNR is specifically Cardio-pulmonary resuscitation – bottom line! We can’t let that morph into something else!

    The problem with DNR’s is also when they put one into a “Living Will.”

    We should never do that, simply because, if I write my living will today, how do I know if, years from now, when that has to be executed, I am going to be in the medical condition to justify this DNR? What if I could live for another number of years?

    We put in a DNR only when we are ready to say that for ourselves – at that time.

  • DNI – Do not intubate This has everything to do with being fed. Do not put this in living will for the same reasons. Pope St. John Paul II said that feeding tubes are ORDINARY CARE & ALWAYS OBLIGATORY. There are certain times when we can take them out:

    1.     If the dying process has already begun. In this case, the nutrition and hydration is not going to be absorbed into the body.

    2.     If we are at a place where it is too difficult to administer (because, for example, the body cannot tolerate the ports).

    3.     If death is IMMANENT – (not next month, not in two weeks, but within hours!) If death is not immanent and we remove food and hydration, they will die of starvation and that is one of the most painful ways to die. It usually takes two weeks for a person to starve to death.

    4.     99.9% of the time, we should keep the food and hydration going.

VI.              Principle of Subsidiarity

Decisions should be made by the “lowest” (the one closest to the person who is dying) level and not the “highest” level.

1.     Lowest level: The free and competent individual has the right to make medical decisions for himself/herself (autonomy).

2.     Parents or loved ones are next – they have the right to make decisions for their family.

3.     Physicians are after parents or loved ones.

VII.           Hospice Care (Palliative Care)

Is artificial hydration and food considered a “natural means” of preserving life or is it considered a “Medical Act” and why is there a qualitative or significant difference?

We live at an unfortunate time when some “Catholic” bioethicists use a number of excuses to justify NOT putting in hydration and nutrition.

They have used the concept of “Medical Means & Spiritual Ends” to justify removing hydration and nutrition. THIS IS FALSE!

They have also changed the term “REASONABLE HOPE OF BENEFIT” TO “REASONABLE HOPE OF RECOVERY.” By those semantic (word) changes (wordsmithing) they are attempting to switch the meaning and to say that nutrition & hydration is NOT ordinary means of preserving life but instead are “medical ends” and because they are medical ends, this is extraordinary care and therefore, not obligatory. THIS IS A DEMONIC DECEPTION!

The Terri Schiavo case is an example. She was in a PVS (persistent vegetative state). She wasn’t dying. To remove hydration and nutrition was THE act that killed her. They manipulated the language to make it look like this wasn’t starvation. Starvation of food and water is a very painful way to die (medically speaking).

• PVS – Persistent Vegetative State

What are we obligated to do?

To answer this, we need to look at “brain death.” There are two main sections of the brain: brain stem and upper brain.

In Terri Schiavo’s case, her brain stem was still alive. She had a problem with her upper brain which ceased giving her the ability to act, think, and do the things an ordinary person can do. Her cognitive functions were injured. BUT SHE WAS NOT DEAD.

Pope St. John Paul II definitively shut this door of food and hydration being considered extraordinary care! He taught in his capacity as Pope that food & hydration are ALWAYS considered “ordinary care” and NOT “medical treatment.”

If you start looking at it as a treatment, you can make other cases and we do NOT want to go there.

VIII.         Hospice Care & Pain Medication Doses

In regards to the administration of pain medication, Hospices are known to GRADUALLY increase the dose until it has reached a LETHAL dose.

The main guideline we need to follow is called “The Principle of Double Effect.”

What this means is that there is one act, which is good in itself, and it has two effects:

1.     The Intended good effect.

2.     The unintended bad or evil effect.

Example: Administration of Morphine

1.     Good effect – relief of pain

2.     Bad effect – it will depress respiration and in doing that, the person will die sooner rather than later. It will “hasten” death. We have to be careful that a “lethal” dose is not given. That would NOT be the authentic interpretation of the principal of double effect.

We should read “Ethical Religious Directives” about Palliative Care https://www.usccb.org/about/doctrine/ethical-and-religious-directives/upload/ethical-religious-directives-catholic-health-service-sixth-edition-2016-06.pdf

Pius XII – “We should do everything we can do to keep a person LUCID while managing their care SO THAT THEY CAN MAKE AMENDS WITH PEOPLE AROUND THEM AND WITH GOD! SO THAT THEY CAN RECEIVE THE SACRAMENTS THAT WILL AID THEM IN THEIR JOURNEY TO ETERNAL LIFE.”

We should not be robbing a person of this opportunity!

We need to remember the value of Redemptive Suffering – if a person is able to unite his/her suffering with Christ, his/her eternal merits are increased and their temporal punishment is decreased! This is an incredible blessing and we don’t want to rob them of this chance!

IX.              Removing a Ventilator

When? It is considered extra-ordinary, not ordinary treatment.

X.                 Living Will vs. Advanced Directives

A living will is a legal document that is almost like a menu – I want this but not that, etc.

A living will is not recommended. Advanced directives are much safer.

XI.              Responsibility of Caregivers

1.     Scripture – 4th Commandment: Honor thy Father and Mother.

      “When I was hungry, you gave me food. Thirsty and you gave me drink.”

2.     Learn – use the resources we have provided to educate yourself.

• www.NCBcenter.org (National Catholic Bioethics Center)

• CMA (Catholic Medical Association)

• OSV

• USCCB