The Linacre Quarterly

Care is often limited by patient age due to societal forces concerning expense and successful outcome. A mother's critical illness yields insights into care that worked despite advanced age. The five subsequent insights are viewed against data from randomized clinical trials illustrating how we know what we think we know. From this a healthcare model is proposed that insures a healthier elderly population.

Public discourse on end-of-life issues involving children and adolescents is often non-existent because of the perception that dying in childhood and adolescence is a rare event, except, perhaps, for premature infants. Yet, every day, families face the death of their children and adolescents, from both chronic and acute conditions. Increased awareness of the developmental and ethical issues facing young patients and their families would assist those caring for them medically and pastorally.

Patients with cardiovascular implantable electronic devices (CIEDs), which include pacemakers and implantable cardioverter-defibrillators (ICDs), may request deactivation of their devices as they approach the end of life. The Heart Rhythm Society (2010) has stated that “ethically, and legally, there are no differences between refusing CIED therapy and requesting withdrawal of CIED therapy.” On the basis of the principle that there is no ethical distinction between withholding and withdrawing treatment, this professional organization has suggested that both the antibradycardia and antitachycardia features of these devices may be disabled at the patient's request. We argue that disabling ICD shocks is analogs to a do-not-resuscitate order and is ethically permissible whereas withdrawing pacing from a pacemaker-dependent patient is an act of intentionally hastening death and not morally licit.

The living will is a document that allows a patient to give instructions about the medical care they desire to receive at a future time. If consistent with Catholic teaching, it becomes a very effective tool for evangelization. A truly Catholic living will addresses five key principles: (1) the desire for pain relief, (2) assessing treatments as either ordinary or extraordinary, (3) providing nutrition and hydration, (4) prohibiting euthanasia, and (5) providing for spiritual care. The Catholic living will is not only individualized and patient-centered, it also avoids the dangers of a secular living will which deny patients proper end-of-life care.

How can we practice dying in community? What communal practices nourish positive acts that make dying well (enough)—more than prudent caution in avoiding causing death (killing)? What part of our common ecclesial life as Catholics enables us to accompany dying persons as a gracious return to God? We are twice haunted: most first world deaths result from foreseen end-stage illnesses; mortality is less feared than burdensomeness for caregivers from vulnerable dependence. Of those who die in the hospital, many deaths result from decisions to withhold and withdraw treatments. From ten kinds of desolation about dying, ten parallel consolations are discerned in hopes and outcomes-based best practices.

The lay Catholic, ordained, and religious today are faced with making legal and medical decisions that will affect their health care during a time of incapacity and eventually the final moments of their life. Often times the response to the need for sound legal and medical instructions is met by non-profit, pro-life organizations which provide legal forms such as powers of attorney. By and large, these documents are morally in line with Catholic Church teaching, but do very little for practical application of the law as it interfaces with medicine in the crucible of the emergency room and courtroom. Thus, the “culture of death” which pervades both the professions of law and medicine, and which veils itself in euphemisms such as a “patient's right to die,” creates pragmatic challenges to pre-printed legal documents which may vary from what are statutory in form for individual states. Thus, the promotion of “living wills” is tantamount to the expression of a fear and human desire to escape suffering at all costs. Accordingly, when Catholic physicians are informed of the legal and moral obligations owed to their patients through various estate planning documents, and Catholic lawyers seek to provide an integrated approach to drafting legal documents which include various provisions grounded in Catholic bioethical teaching, documents such as “living wills” and “advanced directives to physicians” ultimately are seen as unnecessary. Thus, engaging the culture of death is best accomplished when both physician and attorney work in their respective fields of practice by discussing the morality of various bioethical decisions with their patients and clients without fear of legal reprisal or recrimination.

I am often struck at the similarities of caring for older, chronically ill patients, and the long Christian tradition caring for the needy, the poor, and the sick. Particularly when challenged by the scope and size of the task of ministering to this truly underserved population, I find that a spiritual re-focusing provides meaning and comfort. Viewed from the perspective of eternity, end-of-life care occurs in that space between the present and the afterlife. What is the place of spirituality in the care of patients receiving hospice and palliative care? How do Catholic healthcare personnel respond to their patients’ needs? I propose three reflections addressing (1) The Church and human suffering, (2) Catholic framing of goals of care, and (3) Christian stewardship of the cycle of life.

The author identifies an increasingly common phenomenon of sentimentalist “pro-lifers” who embrace physician-assisted suicide and euthanasia because sentimental pro-life slogans readily lead to acceptance of these acts. A more principled and rational opposition to various manifestations of the culture of death including assisted suicide and euthanasia is needed. The author proposes that a robust understanding of compassion and love provide an entry point into the discussion that is both rational and emotional. Drawing upon the magisterial teaching of the Church and lived witnesses to that teaching, the essay shows how suffering with the sufferer is the only fitting response to those who suffer at the end of life. A compassionate presence in which caretakers become co-sufferers treats the patient as a subject with great dignity, while euthanasia and assisted suicide treat him as an object to be discarded.

When caring for of patients suffering from severe anorexia, medical teams may feel deprived in the face of the ambivalent behavior of some of these patients who accept medical care but refuse nutrition. We present here the case of a woman suffering from severe chronic anorexia with a state of morbid malnutrition, which presented the ethical question of how to deal with this unreasonable attitude. These extreme cases raise several questions regarding avoiding malfeasance and when to provide palliative care in a management of psychiatric pathology.