Tuesday, January 5, 2010

One in Five Feeding Tubes "Futile"?

From the BBC, a report on what some call the over-use of feeding tubes in British patients. Now overlay that on the Catholic Church's new Directive #58 which counts feeding tubes as "obligatory" care. I don't mean that the Church would eschew mouth feedings prematurely. But the stats in this quote are applicable.

Doctors described the insertion of a stomach feeding tube as an invasive procedure, which carried a significant risk of infection and even death.

They said feeding difficulties were a "growing problem" on hospital wards and in care homes, because of the rising number of dementia patients.

A survey suggested that, in 2007, 39,000 people in the UK, not including those in hospital, were being artificially fed. A third of them were living in nursing homes.

Other research by doctors who reviewed medical records suggested that one in five cases of tube feeding was "futile".

One in five.

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Anabaptists Sticking It To The Man.



Religious Tolerance and Separation of Church and State.

Marv Knox at Associated Baptist Press applies a little logic and gravity to the Christian claims of religious persecution in the US:

Claims of persecution always deliver a jolt. That’s especially true when a Christian in the United States aspires to be the persecutee. In this context, “persecution” typically means one of three things: Either somebody disagreed with this particular Christian’s beliefs and said so. (What godless rudeness!) Somebody snickered at her religious behavior. (How mean!) Or someone with authority refused to allow him to exert his religious will upon others. (What’s this country coming to?)

Such protests of persecution might appear perplexing or peculiar. Primarily they’re paranoid and provincial. The latest collaborative New Voice Media feature package published today by ABP and its print-media partners presents a broader perspective on persecution. Almost 70 percent of the planet’s population live where religion is highly restricted. Shocking as it may sound, zoning ordinances in American suburbs, banned Scripture signs at public-school ballgames and store clerks who say, “Happy Holidays” don’t make the list. We’re talking about places where people are beaten, imprisoned, banned from the marketplace, denied education and even killed because of their faith. Beside them, U.S. Christians’ claims of persecution are pathetic.

As you might expect, one of the worst perpetrators is China, whose government is atheistic. Interestingly, however, the vast majority of religious persecution takes place in countries that are overtly religious. They’re all for practicing religion -- but only their religion, observed only their way. The most strident are countries politically and/or socially dominated by Islam or some strains of Orthodox Christianity.

Counterintuitively, U.S. Christians who play the persecution card often argue against the policies and principles that ensure not only their religious freedom, but the dream that their great-great grandchildren will have the opportunity to worship and live out faith as they do today.

He goes on to examine the laws that protect separation of church and state and therefore religious freedom. I can't say how refreshing it is to hear the religious left decry some of the challenges to separation and state that we've seen in the past 10 months. Just yesterday I came across about a half dozen blogs that claimed there was no separation of church and state in the constitution and shouldn't be. US law comes from God, I read again and again.

The sheer ignorance of the fact that believers are only allowed such freedoms because of separation of church and state is astounding. It's no secret that the Fundamentalist and Evangelical denominations in the country are out for theocracy. But they forget that they must be careful what they wish for. Theocracy is great so long as the theocrats belong to your denomination.

Only a willful ignorance of this country's history allows such (organized and influential groups) to deny the importance of separation of church and state to their existence. The US was a refuge to those escaping religious persecution in Europe. Our freedoms here rely on the protections established at the time. But those protections have been warped by ignorance of history and unreasonable challenges to secular governance.

As Susan Jacoby writes in The Age of American Unreason, comparing the first and second "Great Awakenings" of fundamentalist faith in the US to the current one, signaled by the rise of the Reagan administration and the claims by the Bush administration that its foreign policy was a "third [Great] Awakening:

Another critical difference between the fundamentalist revivals of the past and the present is the political engagement of modern fundamentalists on the side of one party and their belief that it is both a right and a religious duty to institutionalize their moral values. (pp. 190)

This threat is down-played by both secular and moderate Americans, seen as less of a threat than it actually is. Yet as the past few months have shown with regard to health care reform - and all that I blog about every day! - fundamentalist influence over government is at an all time high and the direct effects on general social welfare are astoundingly profound. From the woman in Kansas who can't find a doctor to perform a tubal ligation after her childbirth to the female soldier who is forced to leave her duties - and career - for an abortion, to the dying patient in Montana forced to be put on artificial nutrition and hydration to the rape victim in Ohio who is denied emergency contraception.

Discrimination is spreading and not only against patients' rights. Discrimination against science and factual analysis of the world around us is part of the Fundamentalist agenda too. History text books are written by Fundamentalists in Texas. Social services are provided by missionizing faith-based organizations which trade food for prayer. Denial of science-based facts, facts which can be proven, is made in favor of pseudoscience and junk science. Our education system places us squarely in the middle of the scale of other Westernized countries, leaving our advancement in the future in question. Our foreign policy ignores dangerous challenges in Christian countries in favor of rebuke - and invasion -of those who do not abide by Fundamental Christianity.

That the religious left is speaking out against this marching and incremental loss of freedom is good. I wish their voices were louder.

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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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Kathryn Tucker on Baxter v. Montana Decision

An interview with Kathryn Tucker of Compassion & Choices on the Montana decision on Baxter v. Montana. From Legal Broadcast Network.

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Religious Left Supports Baxter v. Montana Decision.

Mariya Starchevsky writes about the recent Baxter decision and with (almost too much) surprise notes the religious supporters of the decision to allow aid in dying in Montana.

It's easy to forget that we live in a country of diverse religious practice because typically the loudest and most organized of the crowd are Protestant or Catholic Right. They're the ones with influence, resources, and the power to shape our health care delivery. Their objective is to turn the country and its laws over to God, to delivery social services and health care according to doctrine - and they've been surprisingly successful the past 40 years. But as Starchevsky points out, there are other religious voices out there:

The dispassionate tone of the opinion sweeps under the rug the fiery arguments of amicus curiae.

On the “Pro-Life” side, the International Task Force on Euthanasia argued that allowing physician-assisted suicide would lead to abuse, and intentional killing of the elderly and the incompetent by self-interested relatives and insurance companies. Margaret Dore, Esq., a lawyer from Washington wrote in as well, echoing the Task Force’s sentiment, and claiming that the trial court’s findings were “clearly erroneous because Oregon’s law [on euthanasia] allows involuntary killing.” Page 5.

They are both fantastic reads. I highly recommend them.

But most interesting was the amicus brief filed by religious groups and representatives -
on Mr. Baxter’s behalf!

These were not out-of-state weirdos, or special interest fanatics, but persons of religious authority, and most from Bob Baxter’s home town of Billings, Montana. Making their plead for a right to die from a religious point of view were Rev. Canon Gary Waddingham (Episcopal Priest) Rev. Steve Oreskovich (Episcopal Priest), Rev. Meg Hatch (M. Div, UCC) Chuck Heath (M. Div. LCPC, Chaplain), Reverend John C. Board (Episcopal Deacon) Rev. Jean Collins, (Episcopal Priest), Rev. John R. Payne, Journey BE (Disciples of Christ) and Dr. L.A. Kemmerer (Professor). These authorities then list approximately 70 other religious figures from the United Church of Christ, the Church of England, the Unitarian Universalists Association of Congregations, the Methodist Church, etc., all who support euthanasia when concerning competent, terminally ill adults.
Page 6, footnote 3.

I know what you’re thinking: no Catholics? Well, in the word of Moishe, nobody’s perfect.

Christians believe life is a gift from God. Further, Christians believe that death is not the ultimate enemy nor is the human soul ended by death. The Old and New Testaments teach free will, love, and compassion. God granted humans the ability to choose between good and evil. Page 2.

These religious amici stress that end-of-life decisions are deeply personal.

“Those who do not share in the religious beliefs and doctrines of groups opposed to aid in dying see this as an unwanted intrusion into what should be a private decision making process between patient and physician." - Deric Weiss, M.D.,Billings, Montana.

By the way, I've said some bad things about the Examiner lately. I still stand by them. But nice to see this piece, however irreverent and flippant the tone!

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Once and For All: Aid in Dying in Montana.

I've been enthusiastic about the recent decision by the Montana Supreme Court to allow aid in dying, making Montana the third state in the US to legalize aid in dying. But in truth, the decision gave the Montana Supreme Court only a cameo role in what will prove to be a much longer contentious fight for terminal patients' rights.

The court could have said that aid in dying was constitutional. It did not. It said that there was nothing in the states constitution or laws that prevented aid in dying, almost inviting the legislature, decidedly anti-choice despite public opinion to the contrary, to step in with laws that, as the President of Montana Family Foundation puts it, will end aid in dying "once and for all."

Jeff Laszloffy, president of the Montana Family Foundation, said the battle for life isn't over yet.

"It's up to us now to go into the next legislative session and put a statute in place that completely and once and for all bans physician-assisted suicide in the state of Montana," he said.

Now the question remains to be asked: is aid in dying the same as physician assisted suicide as the "pro-life" religious groups claim?

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Lawyers and the Living Will.

Dr. Muriel Gillick has a must-read article up at her site, Perspectives on Aging, about the problems with living wills (advance directives).

She writes that lawyers have taken up the slack in helping elders fill out living wills and the absence of medical input is creating ineffective and vague forms that give elders a false sense of security over control of their end of life decisions:

The living will my parents were given is a classic example of pseudo-precision: “If a situation should arise in which there is no reasonable expectation of my recovery from extreme physical or mental disability, I direct that I be allowed to die and not be kept alive by medications or artificial means or procedures which serve only to prolong the process of my dying,” it begins. What is a “reasonable expectation of recovery?” A fifty-fifty chance? Is a 30% chance good enough? 10%? What does “recovery” mean anyway? Going home and living independently? Living in a nursing home and needing help with bathing and dressing? Going from unconsciousness and total paralysis to wakefulness and the ability to move one finger?

But there is more—the document seems, at first glance, to spell out the answers to these questions. It says “without limitation, I intend these instructions to apply if I am (i) terminally ill, (ii) permanently unconscious, or (iii) conscious, but have irreversible brain damage and there is no reasonable expectation that I will regain the ability to make decisions and express my wishes.” What is meant by “terminally ill?” Does it mean conforming to the Medicare hospice definition of having a life-expectancy of 6 months or less, if the disease follows its usual course? Does it mean death is imminent—in the next few hours or days? Or does it mean having a disease that is uniformly fatal, such as Alzheimer’s disease, which lasts 3-5 years, sometimes longer, from diagnosis until death? What is “extreme physical or mental disability?” Does this mean the most advanced stage of Alzheimer’s, or does moderately severe dementia—in which the individual can walk and talk, but has completely lost his short term memory and needs help with bathing, toileting, and personal care—qualify?

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Hospital Mergers Expand Catholic Mission of Discriminatory Care.

It's no secret that the Religious Right and the Catholic Right have struck a friendship over the past few decades over their shared desire to stem changes to women's roles in society. It's an alliance that would have been impossible in the 50s when Fundamentalists and Evangelicals considered Catholicism a cult. But the rise of feminism in the 60s and the decision of Roe v. Wade in the 70s brought them together.

As Frances Kissling, former president of Catholics for Choice writes in her article yesterday for Women's Media Center, pro-choice groups first were unsure of whether to work to protect Roe or to stand up to early efforts to restrict abortion access. They wrongly chose to work to protect the court decision. Hyde, she writes:

...first passed at a time that anti-abortion forces were pursuing two lines of attack against legal abortion—an effort to pass a human life amendment to the Constitution, which would make all abortions illegal, and an incremental strategy with the Hyde Amendment the first effort to chip away at Roe. The young prochoice movement realized that its naïve assumption that Roe would end the debate about abortion was wrong and that it needed to mobilize both grass roots and elite support for protecting abortion rights. The tactical question was whether the threat to poor women’s access in Hyde or the threat to all women’s access in the human life amendment would be the best organizing vehicle.

Based substantially on the advice of direct mail and political consultants, the decision was made to put efforts to overturn Hyde on the back burner and go against the less real threat of a constitutional amendment that would ban all abortions. The advice was clear and classist. It accepted the racism that lay buried in middle class hostility to poor women, “welfare queens” and the “sexually promiscuous”—all those who might be expected to look to Medicaid to pay for abortions—whom the rest of us should not support.

Not concentrating on overturning Hyde was arguably the worst decision the mainstream choice movement made. No effort at a constitutional amendment ever got off the ground, but the largely unchallenged Hyde Amendment emboldened anti-abortion groups to pick off powerless constituencies one at a time. From poor women they went on to adolescents and secured “parental consent and notification” laws.

The story of reproductive rights ever since then has been one of constant erosion of access, from parental notification laws, to waiting periods, to state laws regarding Medicaid coverage to a strong effort by the Catholic Church to expand their influence over health care via their hospital network. Today the Catholic Church operates 624 hospitals in the US and three of the top ten health care networks.

From Wendy Norris at RHRealityCheck today comes a story about the contested hospital merger in Colorado and the emboldened Catholic Church placing its health care system under greater pressure to adhere to the Ethical and Religious Directives which impose doctrinal care decisions on Catholic hospital patients.

The merger of publicly funded, tax exempt denominational hospitals - meant to serve entire communities, not just Catholic patients - with secular hospitals is a severely damaging trend for not only women's rights but patients' rights on the whole. If you read here often, you know that the 72 Ethical and Religious Directives not only discriminate against reproductive services but those delivered to gays, unmarried women and elders. When a Catholic hospital merges with a secular hospital, access to essential services for entire communities are eliminated.

For more links about the contested merger, see the bottom of the page.

Norris writes:

Backroom deals, multiple lawsuits and $600 million dollars mark the Sisters of Charity attempt to force religious medical directives on non-sectarian medical centers in Colorado.
A controversial move to transfer operational control of three secular Denver-area hospitals to a Catholic healthcare system expected to take place on December 31 appears to be on hold pending federal approval.
The unexpected delay by the Federal Trade Commission to bless the transaction may provide local critics with a last gasp effort to continue fighting the deal. Community members and medical professionals contend the transfer would unfairly subject comprehensive reproductive health and end-of-life care to church doctrine over patients' needs. The Catholic church considers abortion, contraception, elective sterilization and termination of invasive life support as "intrinsically evil" and refuses to provide these medical services or respect patients' advance directives.

The disputed takeover in Denver exemplifies the very serious implications for the 127 non-denominational hospitals that succumbed to merger fever with cash-flush Catholic health care systems in the 1990s. According to a study by Catholics for Choice, half of merged secular-Catholic hospitals suspended most or all of their reproductive health care services. Eighty-two percent denied emergency contraception to rape victims -- and more than a third refused to provide a referral.

But for some tax-exempt, nonprofit hospitals co-owned by secular and church interests, there was little more than a wink and a nod to church mandates on care. Comprehensive reproductive healthcare services quietly remained available.

These practices received higher scrutiny in 2001 when the U.S. Conference of Catholic Bishops revised its Ethical and Religious Directives for medical care to address "misinterpretation and misapplication of the principle of cooperation with other-than-Catholic organizations." In other words, the church would no longer turn a blind eye to reproductive health and end-of-life care at its secular partner facilities that did not meet strict Catholic orthodoxy.

MergerWatch.org notes several examples of broken promises by Catholic healthcare systems to preserve reproductive health services at non-religious hospitals it acquired through mergers. Typical reasons included newly installed diocesan bishops with more dogmatic views on medical directives or the Vatican overturning decisions made by previously autonomous bishops.

More importantly, the local hospital policymaking was a little noticed precursor to the bare knuckles strategy on recent display with the church's relentless lobbying for the 2009 Stupak and Nelson amendments to further restrict access to abortion care via publicly-subsidized health insurance plans. At the same time, the Catholic Archdiocese of Washington, D.C.,threatened to end social service programs for tens of thousands of poor residents if the city council approved a same-sex marriage ordinance.

Now, the Denver hospital takeover is offering a glimpse of the intense pressure being brought to bear by the church on its healthcare partners. The Vatican's renewed insistence on complete doctrinal influence on patient care is bolstered by very real threats to hold desperately needed institutional capital funds hostage until its theological demands are met.

And that once delicate balance between serving patient needs and adhering to strict Catholic medical directives is unraveling in plain sight.


From lifenews, a crystal clear demonstration of why the oddly allied Fundamentalist Right and Catholic Right support not only this merger but consider mergers a deft strategy in their work to restrict women's reproductive access. They're on a mission from God.

Denver Biz Journal.

Hospital Review.

State Bill Colorado.

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