Update Nutrition & Hydration

Philip Boyle, Ph.D.Vice President, Mission & Ethics

www.CHE.ORG/ETHICS

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Goal• Understand the Catholic tradition

regarding withholding/removing nutrition and hydration

• Recognize the special ethical problems for PVS patients

• Appreciate the state restrictions on removing ANH

Case 1

• 48 year-old woman• Sustained anoxia (10-15 minutes)• Only lower cortical activity• 1 ½ years ago mitral valve surgery she stated

that if she could not recover 50% function, then do nothing, including ANH

• Husband was proxy requested remove everything, including ANH

Case 2

• 60 yr old alcoholic man falls down steps with head bleed

• After 5 weeks in coma eyes open• Children with no POA request remove of

everything including tube feeding • MD certain of his wishes to end treatment• What should the organization chose?

Church Teaching:Placing them in Context

• Encyclicals• Papal Statements

• Congregations (CDF) Congregation for Doctrine of the Faith

• Pontifical Council for Life

-Gospel of Life JPII

-Pius XII

-PJII Allocution 3/25/04

-Declaration on Euthanasia 1980

-”Vatican Statement”

- Responsum

Church Teaching:Placing them in Context

• Bishops Conference– USCCB

• FL Bishops Conference

• Individual Bishops

-Ethical and Religious Directives for Healthcare (ERD) 2001

-Schiavo Statements

Rigali-Lori Health Progress Article

History• 16th Century Dominican – Francisco DeVitoria

addresses the question:– “…would a sick person who does not eat because of

some disgust for food be guilty of a sin equivalent to suicide?...”

– And answers, “…If the patient is so depressed or has lost his appetite so that it is only with the greatest effort that he can eat food, this right away ought to be reckoned as creating a kind of impossibility, and the patient is excused, at least from mortal sin, especially if there is little or no hope of life.”

History

• DeVitoria:

– “Chickens and partridges, even if ordered by the doctor, need not be chosen over eggs and other common items, even if the individual knew for certain that he could live another 20 years by eating such special foods.”

History Pius XII “The Prolongation of Life” 1958• “Normally one is held to use only ordinary means—

according to the circumstances, places, times, culture—that is to say means that do not involve and grave burden for one self or others. A more strict obligations would be too burdensome for most people and would render the attainment of a higher more important good too difficult. Life, health and all temporal activities are subordinated to spiritual ends.”

Appropriate v. inappropriate

Extraordinary v. ordinary

History Declaration on Euthanasia CDF 1980

• “…people prefer to speak of proportionate and disproportionate”…it will be possible to make a correct judgment by studying the type of treatment, its degree of complexity of risk, costs and possibility of using it, and comparing these to the results to be expected taking into account the state of the sick person, and his or her physical and moral resources…when inevitable death is imminent in spite of the treatments used, it is permitted in conscience to make the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due a sick person in similar cases is not interrupted…”

Disproportionate• Excessively burdensome

– Too painful– Too damaging to the patient’s self & functioning– Too psychologically repugnant to the patient– Too suppressive of mental life– Prohibitive cost

• Burdensome to whom?– Patient– Family– Community

ERD

Directive 60• “Euthanasia is an action or omission that of itself

or by intention causes death in order to alleviate suffering. Catholic health care institutions may never condone or participate in euthanasia or assisted suicide in any way.”

Appropriate v. inappropriate

Letting die v. euthanasia

Secondary intent v. direct intent to cause death

ERDs

Directive 57• “A person may forgo extraordinary or

disproportionate 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 the community.”

ERDs

Directive 58• “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.”

Papal Allocution 3/25/05• I should like particularly to underline how the

administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act.

• “Its use (i.e., nutrition and hydration), furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering.

Papal Allocution

• First use of natural means / medical act • In principle, not every case. When?

– Does not nourish – Does not alleviate– Patient finds it excessively burdensome

• Referring to PVS patients– Not immediately applicable to all patients

Florida Bishops 3/28/05

We are called to provide basic means of sustenance such as food and water unless they are doing more harm than good to the patient, or are useless because the patient’s death is imminent.  As long as they effectively provide nourishment and help provide comfort, we should see them as part of what we owe to all who are helpless and in our care.   In certain situations a patient may morally refuse medical treatment and such decisions may properly be seen as an expression of our hope of union with God in the life to come. 

 We pray that Terri Schindler Schiavo's family and friends, and all who hold power over her fate, will see that she continues to receive nourishment, comfort and loving care.

Responsum

• First question: Is the administration of food and water (whether by natural or artificial means) to a patient in a “vegetative state” morally obligatory except when they cannot be assimilated by the patient’s body or cannot be administered to the patient without causing significant physical discomfort?

• Response: Yes. The administration of food and water even by artificial means is, in principle, an ordinary and proportionate means of preserving life. It is therefore obligatory to the extent to which, and for as long as, it is shown to accomplish its proper finality, which is the hydration and nourishment of the patient. In this way suffering and death by starvation and dehydration are prevented.

• Second question: When nutrition and hydration are being supplied by artificial means to a patient in a “permanent vegetative state”, may they be discontinued when competent physicians judge with moral certainty that the patient will never recover consciousness?

• Response: No. A patient in a “permanent vegetative state” is a person with fundamental human dignity and must, therefore, receive ordinary and proportionate care which includes, in principle, the administration of water and food even by artificial means.

Commentary

• When stating that the administration of food and water is morally obligatory in principle,  the Congregation for the Doctrine of the Faith does not exclude the possibility that, in very remote places or in situations of extreme poverty, the artificial provision of food and water may be physically impossible, and then ad impossibilia nemo tenetur. .

Commentary•  However, the obligation to offer the minimal treatments

that are available remains in place, as well as that of obtaining, if possible, the means necessary for an adequate support of life. Nor is the possibility excluded that, due to emerging complications, a patient may be unable to assimilate food and liquids, so that their provision becomes altogether useless. Finally, the possibility is not absolutely excluded that, in some rare cases, artificial nourishment and hydration may be excessively burdensome for the patient or may cause significant physical discomfort, for example resulting from complications in the use of the means employed.

Rigali-Lori • 1. Responsum is “authoritative.”

– What makes authoritative?

• 2. Not restricted to PVS-rare & broad application– Rare?– Broad application--yes

• 3. Withdrawal of ANH is direct cause not due to underlying condition– Agree & questions

Rigali-Lori

• 4. Withdraw for financial hardships is a means to avoid other financial hardships– Means & ends

• 5. Psychic burden not found in allocution– Pius XII

• 6. Living wills permissible only insofar as consistent with Catholic teaching.– Living will not mentioned

Option 1: No change required (benign)

• Narrow application only to PVS

• Continue with tradition and ERDs

• Compatible with PSDA

• Commentary has no authority or limited authority

• Factual issues are wrong– Artificial = natural

Option 2: Some change required

• Narrow application to PVS

• Discontinuous with tradition and requires change to ERDs

• Change informed consent for PVS

• Commentary interpretation of USCCB

Option 3: Radical change• Wide application to any nutrition &

hydration

• Development of tradition and change of ERDs

• Incompatible with PSDA – Ramifications for Catholic healthcare

• Commentary has great authority

Summary– No categorical prohibition– Always a presumption– Clearest:

• Capacitated patients • Patients with clear directives• Patients with little burden/ large benefit/ primary

intent is death

– Greatest concern PVS– Very few PVS patients in our organizations– Option 1 unless or until ERDs are changed

Summary– ERDs must be approved by entire USCCB– USCCB submits to CDF– CDF verbally communicated no change– Universally binding: only universal Church– Local bishops are free to make judgments– Only Responsum, not commentary– Advance directives not mentioned– Ads asking for withholding are not necessarily in

contradictions– Communications: “Catholic institutions follow the

wishes of patients insofar as they are consistent with tradition”

– Very few ask for treatments that cannot be honored