If a patient or family didn't want a feeding tube "and the reason they don't want it is they basically want to die, then the Catholic institution would explain to them they can't cooperate with that and they would have to go to another institution," said the Rev. Thomas G. Weinandy, executive director for doctrine at the bishops' conference, who helped draft the policy.
Experts say no other large health systems in the U.S. have nutrition and hydration policies like those governing Catholic facilities.
Catholic officials have said the directive is consistent with previous doctrine. But the revised language eliminates what many Catholic ethicists viewed as flexibility in its application to patients in a persistent vegetative state. The previous policy said "there should be a presumption in favor of" use of feeding tubes, rather than an "obligation."
Morever, according to Catholic officials and outside experts, the directive may well 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 downplays the impact. Experts say this affected group could include those with massive strokes, advanced Alzheimer's disease, traumatic brain injury and Lou Gehrig's Disease.
"If someone had a stroke and the doctor says he won't die though he may be very sick, then they should give him nutrition and hydration," Weinandy said. "You can't just starve him to death. It's hard to know whether someone can regain consciousness or not."
Dr. Lachlan Forrow, a Harvard University medical ethicist and palliative care specialist, expressed strong concern about the new policy, stressing its potentially broad scope. "That gets to be a very, very large number of people," said Forrow, who heads a panel developing recommendations for the state of Massachusetts on end-of-life care.
Forrow also said Catholic health facilities haven't met a key ethical test - adequately informing the public of their policy. If they don't do so, "patients and their families will arrive at the hospital in crisis and find that the care they want and need and have a right to as Americans is being refused."
Weinandy said "obviously the public should know what the directives say," and patients and relatives "can easily download the directives or get a copy."
The revised directive arises from statements made by Pope John Paul II in 2004 during the legal battle surrounding Terry Schiavo, the Florida woman kept alive on a feeding tube for nearly 15 years, and from clarifying statements by Vatican officials in 2007.
Sister Carol Keehan, executive director of the Catholic Health Association representing hospitals and other facilities, said the bishops' point is "you don't have the right to just stop feeding them because their life is a burden." But the new policy, in her view, would come into play infrequently, mainly in cases involving a persistent vegetative state. For that reason, said the CHA senior director for ethics, Ron Hamel, "There probably was not much publicizing" of the revised directive by Catholic facilities.
There are more than 600 Catholic hospitals and hundreds of nursing homes and other facilities; the hospitals alone admit nearly six million patients a year. Keehan doesn't see much potential for conflict between patients' and families' end-of-life wishes and the new directive. "Advance directives are held in great respect in Catholic hospitals," she said in a recent interview. "Some might like to say there's a terrible problem, but there isn't."
Most states require honoring a patient's advance directive or the designated proxy's decisions in end-of-life situations — or else transferring the patient to a facility that will honor those wishes. It is against the law in every state to place a feeding tube or provide other medical treatments against the expressed wishes of the patient.