Tuesday, January 5, 2010

PalliMed Discusses USCCB Change to Artificial Nutrition and Hydration Policy.

The mercurial Barbara Coombs Lee has been doing the heavy-lifting on making the public aware of the November decision by the USCCB to change their Ethical and Religious Directive regarding artificial nutrition and hydration.

Now medical practitioners are getting involved and I couldn't be happier to see this post at one of my favorite sites, PalliMed, today.

And just to emphasize why this is such an important issue: The Catholic Church is the second largest provider of health care in the US; they manage 624 hospitals and three of the top 10 health care networks. Doctrinal provision of health care services, despite tax-exempt status and 50% funding by the federal government, continues to expand. While Catholic health providers generally do a fantastic job of running hospitals and caring for patients, they do so with discrimination against any services that do not meet the 72 Ethical and Religious Directives. Remember that the next time you or a loved one are on your way to the hospital.

In November of 2009, the United States Council of Catholic Bishops voted to approve and update the Ethical and Religious Directives for Catholic Health Care Services. Some of the wording changes have begun to worry some in health care about how to handle delicate discussions in Catholic health care facilities that may be caring for patients wishing to forego artificial nutrition and hydration. The most vocal group thus far is Compassion & Choices. The NHPCO, AAHPM and HPNA have been relatively silent on this matter either way to my knowledge.

The section on End of Life starts on page 29 and begins with an introduction reviewing Catholic teachings on matters pertaining to death in the modern medical age. From the intro:

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” (PVS), because even the most severely debilitated and helpless patient retains the full dignity of a human person and must receive ordinary and proportionate care.

Following the intro are the directives which I have highlighted a few pertaining to artificial hydration and nutrition.

58. In principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic and presumably irreversible conditions (e.g., the “persistent vegetative state”) who can reasonably be expected to live indefinitely if given such care.40 Medically assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be “excessively burdensome for the patient or [would] cause significant physical discomfort, for example resulting from complications in the use of the means employed.”41 For instance, as a patient draws close to inevitable death from an underlying progressive and fatal condition, certain measures to provide nutrition and hydration may become excessively burdensome and therefore not obligatory in light of their very limited ability to prolong life or provide comfort.
59. The free and informed judgment made by a competent adult patient concerning the use or withdrawal of life-sustaining procedures should always be respected and normally complied with, unless it is contrary to Catholic moral teaching.

The main revision comes in ERD #58 which changed the wording from "presumption in favor of providing nutrition and hydration to all patients" to "[moral] obligation" to provide food and water. other clarifying points was to highlight those in a chronic condition or the chance to live chronically with the assistance of artificial nutrition and hydration (ANH) cannot forego or refuse ANH in a Catholic Health Care Facility.

Most of the hub-bub has focused on patients in a persistent vegetative state, but since those cases are actually pretty rare, I think where this might be more likely to be a potential ethical conflict is in the care of patients after a stroke or those who become chronically critically ill. In those patient groups predicting death or the impending nature of death become much more difficult especially if you factor in the variable of +/- ANH. If you think having members of the church directly becoming involved in health care matters seems theoretical or indirect at best, consider the case of Mr. Welby in Italy in 2006, or Steven Becker in St. Louis in 2000.

The Catholic Health Association of the United States (CHA) issued a clarifying statement. And in other statements has said if a resolution could not be found, the patient would be transferred to another facility.

For more information on this you can read a good synopsis with interviews from Charles Stanley at Atlanta's The Sunday Paper. Also on the Compassion and Choices blog. And the San Francisco Examiner. Or from the blogotherspoon.

I would encourage anyone who does work with a Catholic hospital, nursing home or hospice to proactively address the handling of this directive so there is some clear understanding of the implications and the channels any decision making should go through. Maybe it is a good time to convene the ethics committee to review the directive and current practices regarding ANH. I do palliative care consults at a Catholic hospital so I know I will be meeting with the administration and ethics committee within the next few weeks to review this issue. If you have any experience with this please feel free to post in the comments or email me at ctsinclair@gmail.com.

Thanks for the link, Dr. Sinclair.

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