Gerald D. Coleman
Catholic wisdom on end-of-life care
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A number of high-profile legal cases since the 1980s have involved persons receiving medically assisted nutrition and hydration (food and water): Claire Conroy, Paul Brophy, Nancy Cruzan, Hugh Finn and Terri Schiavo. The provision of nutrition and hydration through various medical interventions, generally described as “tube feeding,” is one of the most complex and controversial issues in contemporary bioethics.

Such relatively common legal and moral debates are concerned with persons who are in a persistent vegetative state. While some brain functions, like wake/sleep cycles and spontaneous/automatic reflex actions of the nervous system may continue, all detectible activity of their neocortex has stopped. A diagnosis of PVS means that the doctor sees virtually no prospect for the patient’s recovery.

Nutrition and hydration can be provided by medical means, which are sometimes wrongly called “artificial.” A tube, for example, can be inserted through the nose and into the stomach, a method usually employed for short-term use. Other tube-feeding methods require surgery. A tube can be passed through an incision in the abdominal wall and into the stomach, for example, or through the abdomen into a portion of the small intestine. In such cases, feeding tubes and incisions need consistent monitoring.

To make an informed decision about the use of tube feeding, one must consider several factors, like a patient’s diagnosis, prognosis and current condition, as well as any complicating factors like the presence of renal failure and pneumonia. A number of relevant questions also should be asked: What medical method is best suited for this person and for how long? What are the benefits and burdens of various methods? What are their side effects? In short, there is no single or simple answer to the questions surrounding tube feeding.

In the past several decades, more than 40 courts in the United States have addressed medically assisted nutrition and hydration. As a result, there is a virtually universal legal consensus that tube feeding is a medical treatment that may, depending on the result of a careful decision-making process, be withheld or withdrawn. Less unanimity, however, exists in the medical and moral fields. Clinicians agree that withholding or withdrawing a feeding tube is appropriate when 1) it is medically futile—that is, does not provide effective nutritional support or prevent dehydration; 2) the patient would experience no real benefit; 3) the burdens for the patient outweigh the benefits; and 4) the patient is dying.

Given this complex history, it is not surprising that within the Catholic tradition a number of theologians, ethicists and groups of bishops have come to different conclusions regarding the use of tube feeding. The pivotal question for them has been: Is tube feeding a medical intervention—not just basic care—that can be morally evaluated using the traditional distinction between ordinary and extraordinary means of care? Other questions further complicate the issue: Can a persistent vegetative state be diagnosed with certitude? How does one determine the quality of life of a patient in this state?

What the Church Teaches

In March 2004 an International Congress took place in Rome with the title Life-Sustaining Treatments and the Vegetative State: Scientific Progress and Ethical Dilemmas. There Pope John Paul II delivered an allocution that encouraged scientists and researchers to find ways to diagnose PVS more accurately. He referred to studies showing that up to 43 percent of patients were misdiagnosed and to cases of patient recovery after a period of time with sustained rehabilitative efforts. He also acknowledged that recovery is more difficult the longer the condition of the vegetative state remains.

The papal allocution strongly reaffirms the intrinsic worth and the personal dignity of every person, including those in the PVS, and insists on their right to basic health care, particularly nutrition and hydration, hygiene, a comfortable environment and the prevention of complications resulting from bed confinement. In other words, such patients retain their moral claim to basic health care.

John Paul II’s allocution also underscores that the administration of food and water—even when given by medical means, including feeding tubes—is a natural way of conserving life. The use of medically assisted nutrition and hydration, it said, should be presumed “in principle.” Clear medical reasons are to be given in each particular case to demonstrate why such assistance is not morally obligatory.

The moral obligation to provide medically assisted nutrition and hydration, then, is conditioned by medical efficacy. Do the means used achieve the proper goal, which is to nourish the patient and alleviate suffering? When it is medically demonstrable that these goals are not being achieved, however, the moral obligation to use tube feeding ceases.

While the giving of nutrition and hydration is considered ordinary care even when medically administered, its use is bound by the church’s traditional discernment of ordinary/proportionate and extraordinary/disproportionate means (see Declaration on Euthanasia, 1980).

The pope’s allocution underscores the following key points: 1) All human persons, regardless of their state of development or decline, possess an inviolable dignity; 2) Every person has a right to receive ordinary health care to preserve life and alleviate suffering; 3) The decision regarding the use of medically assisted nutrition and hydration must be based on the actual medical condition of the patient; and 4) An exception can be made if tube feeding is determined to be disproportionate or medically futile, in which case the intervention may be withheld or withdrawn. In all cases the patient is to remain the subject of care, comfort and love. The Congregation for the Doctrine of the Faith reaffirmed these teachings of John Paul II in 2007.

In the United States, the guiding principles for Catholic health care facilities and services are contained in the Ethical and Religious Directives for Catholic Health Care Services, issued by the U.S. Conference of Catholic Bishops. From time to time, these directives are revised in light of official church teaching or to include new or updated directives that address medical and moral concerns. The directives currently in use (the fifth edition) were approved and published in 1995 and have been revised twice since then.

Directive 58

The latest revision concerns Directive 58, which the bishops approved on Nov. 17, 2009, to incorporate both the teaching of John Paul II in 2004 and its affirmation by the Congregation for the Doctrine of the Faith three years later. A news release issued by the Catholic Health Association on Nov. 18 explained: “The revised Directive does not offer new teaching but rather reflects existing Church teaching which Catholic health care facilities have already incorporated into their practice.”

In conformity with the papal allocution, the revised Directive 58 makes the following points: 1) In principle there is a general moral obligation to provide patients with food and water, including medically administered nutrition and hydration for those who are unable to take food orally, even if assisted; 2) This moral obligation extends to patients in a persistent vegetative state because of their innate human dignity; 3) This moral obligation ceases or becomes “morally optional” when tube feeding becomes excessively burdensome or no longer accomplishes its objective—that is, when medically administered food and water are no longer being assimilated by the patient; 4) It is necessary to distinguish between patients in a chronic state, like PVS, and patients who are dying.

Accordingly, the revised introduction to Part Five of the E.R.D.’s, which includes Directive 58, states, “While medically assisted nutrition and hydration are not morally obligatory in certain cases, these forms of basic care should in principle be provided to all patients who need them, including patients diagnosed as being in a ‘persistent vegetative state,’ because even the most severely debilitated and helpless patient retains the full dignity of a human person and must receive ordinary and proportionate care.”

Spread of Misinformation

Despite repeated, official attempts to clarify Catholic teaching on the use of medically assisted nutrition and hydration, false and misleading information about the revision of Directive 58 persists.

One journalist who specializes in health care asserted (modernhealthcare.com, 11/17/09) that Catholic hospitals must now insert and maintain nutrition and hydration tubes, and that all PVS patients must be given medically assisted nutrition and hydration except those close to inevitable death from underlying conditions. This assertion is incorrect. The church’s teaching is not that every PVS patient or patient with a chronic condition must be maintained on feeding tubes until diagnosed as dying.

Rather, by use of the phrase “in principle” in the papal allocution, in the C.D.F. response and in the Ethical and Religious Directives, the church acknowledges that tube feeding may become medically futile for a patient. The C.D.F. laid out several clear examples: settings in which tube feeding is not available, as in a remote place or in a situation of poverty; when complications emerge so that a patient is no longer assimilating the nourishment; or when such assistance causes a patient significant physical discomfort.

A misinterpretation of the church’s teaching can be and already has been adopted by other groups that espouse purposes contrary to Catholic teaching. The organization Compassion and Choices, for example, a leading force behind efforts to legalize assisted suicide, has misrepresented the revision of Directive 58. A regular writer on their Web site, Barbara Coombs Lee, claims (wrongly) that Catholic health care institutions will no longer honor patients’ advance directives and that patients in a persistent vegetative state will be force-fed against their will (see compassionandchoices.org/blog/?cat=27). She states falsely that by removing all flexibility to respect the wishes of a patient or family, the revised directive creates an obligation to provide patients medically assisted nutrition and hydration in all circumstances, and that the new guidelines allow no consideration of the burden to the patient. These assertions are absurd.

In fact Directives 24 and 25 support such advance directives as a durable power of attorney for health care. One can even indicate in one’s advance directive that medically assisted nutrition and hydration is not to be administered because of one’s “psychological dread” of tube feeding. Psychological dread is one of the accepted and traditional moral categories that can constitute extraordinary or disproportionate means (see “A History of Extraordinary Means,” Ethics and Medics, September and November 2006). Reasonable persons might regard tube feeding as excessively burdensome because it causes them great dread (vehemens horror).

Directive 24 cautions that a Catholic health institution “will not honor an advance directive that is contrary to Catholic teaching.” In light of the revised Directive 58, an example of such an advance directive would be that of a person who does not want tube feeding if diagnosed as in a permanent vegetative state for the reason that such a patient has lost all human dignity and is dying. This reasoning runs counter to Catholic teaching, since PVS patients have an intrinsic dignity that demands equality of health care. One could think of other such examples. The bottom line is that a diagnosis of unconsciousness or of PVS can never in itself be the basis for withholding or withdrawing health care that would be given to others who are not in such a state.

Read this article in Spanish. Translation courtesy Mirada Global.

Gerald D. Coleman, S.S., is vice president for corporate ethics for the Daughters of Charity Health System and a lecturer in moral theology at Santa Clara University in California.

Comments

Jim White | 9/3/2010 - 11:57am
The church sincerely attempts to provide clarity and direction related to end of life care based on the wisdom of our faith and what is best for the human person. Unfortunately, many read their teachings as information we need to know to live and act within the Truth to achieve salvation. This can and does lead to distortions of Catholic teaching illustrated in the article. Dogma tends to discourage living in the real world where tough decisions and real suffering exist. The faithful are often more concerned with obedience to dogma than the pastoral intent of many church teachings. Agitated and self righteous confusion and anger results.
Redemptive suffering is a concept I have heard tossed around the Catholic community and John Paul II is often cited as its author. This can confuse the issue further when the church teaches that tube feeding can be stopped if it is causing suffering to the patient and is having no effect. For many, the alleviation of suffering related to "respect of life" issues is not high on the moral "to do" list. A narrowly defined life agenda trumps everything. Aggressive forms of pain management are also looked at with skepticism when the alleviation of suffering is seen as a goal. Better to suffer than to indirectly hasten death.
As a hospice worker I have seen the fear of liability within nursing homes drive decisions regarding tube feeding and hydration more than a commitment to the dignity of the human person. Corporate greed is having an impact on the treatment of the elderly and this is also a moral issue.
LAWRENCE HANSEN | 9/1/2010 - 9:44pm
As a hospice Chaplain, I read Fr. Coleman's attempt to explain Roman Catholic ethical rationale with an increasing concern that he has contributed to the ongoing confusion and therefore misguided thinking among the average Roman Catholic layperson.  Frankly, I fail to understand how anyone can state with a straight face that the artificial insertion of a feeding and/or hydration tube into the body of permanently-comatose patient is not to be considered "extraordinary," but "natural." 

From the act of placing silver nitrate into a newborn infant's eyes to prevent congenital blindness to the moment we withdraw the paddles from a dead 70 year-old heart attack victim, we have intervened in the "natural" process of living and dying.  It falls to us to make decisions that, for most of human history, have been left up to God.  That means that we have to bring to bear a number of factors when considering any kind of medical intervention.  Perhaps most important is one noted by David Kelly in his work, "Medical Care at the End of Life: A Catholic Perspective;" that is, that we must take into consideration the effect of a procedure on the person in her or his total personhood.  A needle biopsy of a breast tumor for a 25 year-old woman is often considered good medicine.  The same procedure on a demented, frightened 85 year-old woman with congestive heart failure and emphysema who is close to death might well be considered cruel.  To employ medical technology to assist people in their journey back to some degree of health is laudable.  To use it to extend the dying process is truly to "tempt the Lord." 

A Roman Catholic priest once opined in a homily that "to read the Bible does not absolve one of the responsibility of thinking."  I would offer the same advice to anyone plowing through the heavy tomes being put forth by the Bishops and the Vatican on this subject.
CHARLES MACCARTHY | 8/31/2010 - 10:34pm
Further comment about "tube feeding" in the Hospice setting would have been helpful. This can be a mechanism to extend life, or to extend suffering for patient and family. Like other medical interventions, it needs to be evaluated in each individual situation. What exactly is hoped to be gained, and what are the risks and costs involved? What are the expressed wishes of the patient?

I have been impressed that the "multi disciplinary group" with nurses, physicians, counselors and pastoral care representatives often has a better, practical answer to this situation than "ethicists" in Rome or elsewhere, because they know the family members, and the situation of the individual patient. 

Frank Bergen | 8/27/2010 - 5:31pm
Is there not a contradiction between respect for the dignity of the human person, even in PVS, and the demand that such person be kept "nourished" and "hydrated" through a surgically-installed "feeding" tube?  Can one die naturally and with dignity intact while being subjected to such an inhumane medical procedure which is without realistic possibility of permitting reversal of the PVS and regained health?
David Pasinski | 8/26/2010 - 9:26pm
I believe Nancy raises a core question of patient - and family- self determination.  It is simply ludicrous to believe that we are respecting the gift of life and God's created image in each person with such directives. The bishops  may be helpful in reminding us of the core values, but they are woefully out of touch and caught up in compliance. I have a very special relationship with our Catholic hospital and could not imagine asking for another one for my father or myself, but interpretations like the above - and even this final paragraph of Coleman - make me rethink that in certain circumstances.
Nancy MacLachlan | 8/24/2010 - 9:14pm
This article in the Tulsa World, and subsequent discussions with his pastor in Tulsa,  caused my father to feel he needed to rewrite his advance directives in order to be a good Catholic.  The article makes the statement: "Also, according to Catholic officials and outside experts, the directive may apply to a wider range of patients, those that it describes as having "chronic and presumably irreversible conditions", though the organization representing Catholic health facilities dwowplays the effect.  Experts say this affected group could include those with massive strokes, advanced Alzheimer's disease, traumatic brain injury, and Lou Gehrig's Disease."

http://www.tulsaworld.com/news/article.aspx?subjectid=18&articleid=20100314_18_A18_Anelde557759&archive=yes


The priest told my father that his end-stage heart disease would not preclude him from needing to use artificial nutrition and hydration were he to become unconcious.

When did this directive morph into something that includes so many diagnoses from the original PVS?  When was the person's right to decide the burden vs. benefit of his/her own treatment revoked?  My father has held that artificial nutrition and hydration were not to be used in his end-of-life care since 1993.  My mother died last year after 11 years of Alzheimer's when she could no longer swallow without choking. It had been her wish that she not be kept alive by artificial means.  The Church has taught me that I am to respect life from"natural conception to natural death".  When did the Church change her mind about allowing natural death?

Joan Carroll | 8/24/2010 - 4:09pm
Nursing homes have boiled all this hifalutin philosophy down to "if you want to go to a Catholic nursing home, you have to have a feeding tube." 

The real issue is that it is much cheaper for the nursing home to drip or pour a can of liquid into a feeding tube than to employ expensively trained aides to hand feed patients with advanced dementia, who are no longer able to eat. If the Catholic Church wanted to do something useful, it could organize an army feeding volunteers to go and hand feed patients three times a day.  A human being is not a machine that you just pour a can of fluid (which gives you diarrhea) into several times a day.

 An article in the New York Times last week reported that feeding tubes do not prolong life in patients with advanced dementia.  Advanced dementia is a progressive (gets worse) terminal condition, in and of itself.  So most patients with dementia who need feeding tubes are within weeks of their deaths.

Hospices often offer "comfort feeding" whereby patients are offered food and fluids, but if they don't want or can't take them, that's the end of it. But nursing homes do not offer this.  Probably too hard to supervise staff, who might be tempted to not do the comfort feeding, or to make a deliberately half-hearted effort.

I am an physician anesthesiologist who has cringed over the last three years every time I have been called upon to sedate an extremely sick, frail, high risk patient with end stage dementia to place a feeding tube.  I have often said to my colleagues, I wish the Catholic bishops could see this. 

In my  opinion, the only ones who benefit from placing feeding tubes in patients with advanced dementia are the greedy gastroenterologists who have no long term re?l?ations?hip with the patients or their families, and get ?a a ???fee for each of these fee?ding tubes they place in dying patients.
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Joseph Legan | 8/23/2010 - 5:30pm
Excellent article and adds clarity to the US Bishop's position.  For many people in this position, the trick remains to define PVS.