Bishop's Blog

End of Life Issues and Palliative Care

In a recent homily, following the proclamation of the Gospel story of Jesus, Jairus and his little twelve year old daughter, and the woman who had been suffering from haemorrhages for twelve years, I told the following story:

A friend was visiting the chaplain of a hospice. In the course of the conversation, the chaplain said that on the past weekend eight, of the hospice's 30 patients had died. The visitor asked about the effect of so many deaths on the staff. The chaplain explained that it was tough, and shared one particular story from the weekend.

On Saturday, a woman who had been at the hospice for a couple of months had a visit from her teenage son. It was a great visit, filled with laughs and fun and hugs. At noon the boy told his mother that he was going to have lunch with his friends but that he would be back later in the afternoon.

Shortly after the son left, the mother called the nurse on duty, a wonderful young woman who was the patient's favourite nurse. She said, "I think this is it. I may be dying," The nurse checked her vital signs and replied honestly, "it's possible that you are."

The patient then asked the nurse, "Will you hold me? I think if you hold me I can do this well." The young nurse did not hesitate, she reached across the bed and began to cradle the emaciated body of the woman in her arms, and held her into eternity.

The visitor then asked the chaplain, "What about the nurse? What did it do to her?" And the chaplain replied that the nurse had taken four days off to go to the mountains to think, and feel, and decide whether to come back to work again.

"Do you think she'll be back?" the chaplain was asked. "She'll be back. You learn in a place like this that caring hurts - but when you really care, you offer something special - and become special yourself."

We are all going to die. The number of people requiring end of life care is growing as the population grows and the baby boomers reach an age where terminal illness and age increase the number of patients entering the health care system. The health care system is geared to healing not dying. Often, patients and their families are unable to manage pain and symptoms at home and, often, unnecessary tests and treatments are prescribed to dying patients, leading to unnecessary and unwanted hospital stays and undue complications. We need more palliative care.

Palliative care involves a comprehensive plan for serving the needs of persons who are ill, who usually are living with a terminal illness or chronic diagnosis for which care can be provided but for which a cure is not anticipated.

The World Health Organization calls palliative care an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psycho social and spiritual.

Quality-of-life considerations are a relevant aspect of moral reflection when considering whether a patient may abandon a particular treatment. For example, a patient who is already suffering multiple complications, such as congestive heart failure, stroke, and persistent bed sores, will not be a good candidate for a risky course of surgery. Even if the patient survived the surgery, the prospects for a reasonable quality of life are so greatly diminished by the complicating factors that the surgery would be inadvisable. The potential benefits simply do not outweigh the burdens.

This is very different from saying that those who are seriously disabled do not have lives worth living. Talk about quality of life should never suggest that the life of any patient has no value. Life itself is an intrinsic good and so always possesses value. What is at issue is the condition of the patient, the state of disease, and the resources that are available to combat it, or if necessary, continue to live with it. If we distinguish between the good of life that always belongs to the patient, and the condition of life that the patient currently experiences, it is possible to make a quality-of-life assessment without denigrating the person.

The problem arises when the value of the person is called into question by those who would say that life becomes "worthless" when it is not of a sufficient quality, usually meaning that the patient has lost some or all higher cognitive abilities. We cannot associate loss of consciousness with the loss of value.

Another difficult area for judgment concerns patients whose lives can be saved after a traumatic event but who are not likely to return to a meaningful level of recovery. Here again it would seem unnecessarily rigorous to hold that measures must always be taken so long as there is any possibility of continued life.

If the means to preserve the life of the patient require minimal effort, then these means must be employed. But it is also reasonable to hold that if the patient cannot hope for a meaningful level of recovery, then the measure of an ordinary course of treatment diminishes considerably. Although a permanent loss of consciousness is not a reason to diminish the value of a person, the decision to restrict care to comfort measures can be an appropriate and justifiable response to this diminished quality of life. Cognitive powers are vital to our personal identity; their loss cannot help but affect an assessment of what treatment options should be pursued.

Returning to my opening story, I can?t help but wonder if the woman prayed for a happy death. Part of my upbringing was the prayer to St. Joseph:

O Glorious St. Joseph, behold I choose thee today for my special patron in life and at the hour of my death. Preserve and increase in me the spirit of prayer and fervor in the service of God. Remove far from me every kind of sin; obtain for me that my death may not come upon me unawares, but that I may have time to confess my sins sacramentally and to bewail them with a most perfect understanding and a most sincere and perfect contrition, in order that I may breathe forth my soul into the hands of Jesus and Mary. Amen.

☩ Frederick Henry
Bishop Emeritus

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Reflections on Life and Suffering

Most of the time we don’t think about eternal life, just about the problems of this life. There is a story about a man who wanders the world asking, “What is life?” Finally he hears about a wise holy man high up on a holy mountain, and he climbs over glaciers, to be in the sage’s presence. “You disturb my silence,” says the sage. “Ask three questions and go!”

“What is life?” shouts the seeker through the howling wind. “Problems and suffering,” moaned the sage. “And beyond those?” “More problems, more suffering. Your third question please.”

“Is there another mystic higher up?” hissed the seeker.

But the sage was right, and second opinions don’t help. As a child I used to think that after exams, life would be problem-free – just as after a recession, life would be lovely. But when we solve one problem, another takes its place. It’s not so much that life is problems but they certainly do stand out. And we are driven to ask “why?”

Rev. Bede Jarret, O.P. opines poetically: “Life is eternal and love immortal, and death is only an horizon, and an horizon is nothing save the limit of our sight.”

My first encounter as a priest with death occurred shortly after my ordination in 1968. I had just finished celebrating the 5:15 p.m. mass, and Msgr. Mugan asked me if I would go over to the Rossi’s as Mr. Rossi had just dropped dead of an apparent heart attack. I jumped in the car, raced over, and found Mr. Rossi already cold to the touch, lying on the garage floor. I conditionally anointed him. Upon entering the house, I found Mrs. Rossi was sitting at the kitchen table in a state of shock, very subdued, downcast, absorbed in her own thoughts and sense of loss. When she saw me, she began to come out of her deep solitude and pounded the table repeatedly asking “why?”

I didn’t know what to do. Obviously, this was not the time to try and give a long catechesis on the mystery of suffering and death, so I simply sat down beside her, held her hands and said: “I don’t know – all I can tell you is that God loves you, He loves your husband, and we pray that Mr. Rossi is now with Him in heaven.” Then, uncharacteristically, I shut up. After few minutes, many neighbours and friends began to assemble, bringing support but adding to the chaos. I made a quiet exit telling Mrs. Rossi that we would sort things out with the funeral home.

Following the funeral, word got back to me that Mrs. Rossi was telling everyone that the new young priest was very kind, “he spent two hours with me the day my husband died.” It was really only ten minutes. The whole experience taught me a great deal about words not always being that important compared to presence, solidarity and faith in the midst of suffering, pain, and death. To be with another can be a timeless experience.

People of faith “live to die.” For the believer, the moment of death is the most important moment of “earthly” life. However, many people fear and wish to avoid death. There are also many families who do not want their loved ones to be told that death is near.

It should be understood that the one who is dying has the right and a need to know that death is imminent. A person in danger of death should be provided with opportunities to prepare for death. This entails being provided with information to help them understand their condition, as well as the opportunity to receive the sacraments.

When faced with a terminal illness, questions arise concerning the meaning of suffering. In addition to all the questions about pain management, other questions tend to surface in three domains:

1. Spiritual suffering: What do I really believe? Am I ready to meet my God? What is my unfinished business? What can I do to make peace with my God? Will God be merciful?

2. Emotional suffering: What bothers me the most? What relationships are unreconciled? Whom do I need to see and talk to before I die? How have I loved? How could I have been a better mother or father?

3. Psychological suffering: Who am I? Who have I become? Have I used the talents God gave me? Did I share them with others?

John Paul II, in his apostolic letter Salvifici doloris, states that Sacred Scripture is a great book about suffering. Christ is the center of Sacred Scripture—this tells us that suffering is a key theme in his life. In the New Testament, Christ shows his concern consistently to those who suffer. He heals the sick, consoles the afflicted, feeds the hungry, frees people from deafness, from blindness, from leprosy, and from the devil. He is very sensitive to human suffering. Jesus washes the feet of his disciples. It is precisely through suffering, through his own suffering, that Christ saves us and opens the way to eternal life.

This is the catechesis to offer especially for persons facing terminal illness—to assure them that they are loved and their suffering has meaning. Pastorally, I have found that, in addition to words, giving someone the rosary or a crucifix to hang onto, brings great consolation. Christ suffers voluntarily and suffers innocently. Suffering is the way to “mount the Cross,” the way to unite with the love of Christ.

The powerful mandate to co-suffer, to be a companion to another, is the opportunity that palliative and hospice care offer. Pope Benedict XVI in his encyclical letter on hope, Spe salvi, offers a deep understanding of co-suffering and compassion:

“The true measure of humanity is essentially determined in relationship to suffering and to the sufferer. This holds true both for the individual and for society. A society unable to accept its suffering members and incapable of helping to share their suffering and to bear it inwardly through “compassion” is a cruel and inhuman society” [38].

☩ Frederick Henry
Bishop Emeritus

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Making Ethical Decisions

A farmer hired a man to work for him. He told him his first task would be to paint the barn and said it should take him about three days to complete. But the hired man was finished in one day.

The farmer set him to cutting wood, telling him it would require about 4 days. The hired man finished in a day and a half, to the farmer's amazement.

The next task was to sort out a large pile of potatoes. He was to arrange them into three piles: seed potatoes, food for the hogs, and potatoes that were good enough to sell. The farmer said it was a small job and shouldn't take long at all. At the end of the day the farmer came back and found the hired man had barely started.

"What's the matter here?" the farmer asked. "I can work hard, but I can't make decisions!" replied the hired man.

All of us are called to make decisions. One of the existentialist philosophers even said that "we are condemned to choose." Some people hope and pray that if they delay or stall long enough that either the problem will get resolved on its own or mysteriously disappear. Experience would seem to suggest that this rarely works. Most of us need to discern and it's hard to improve upon the old discernent process of SEE, JUDGE, and ACT and to do so in prayer and quiet reflection.

SEE - identify the problem, name it clearly, where is the conflict. What are my "gut" reactions, biases, and loyalties?

JUDGE - consider the alternatives, examine the values, evaluate the alternatives, what principles are involved, what consequences?

ACT - articulate the decision and implement the plan.

Our Catholic tradition has always respected the role of both faith and reason in ethical discernment. The teachings of the faith are not contrary to reason, nor is the use of reason a denial of the need of faith for deeper spiritual insight and significance. The magisterium or teaching authority of the church provides the authoritative interpretation of the moral law, based upon Sacred Scripture, natural law and tradition. In this way, the individual's conscience, with its limitations, avails itself of the accumulated wisdom of the Church.

The Catholic Health Alliance of Canada in the 2012 Health Ethics Guide summarized some important interpretive principles that aid in interpreting particular kinds of moral situations.

1. Burden and benefit - This principle states that we are not obliged to begin or continue treatments that offer no reasonable hope of benefit, or that may constitute a grave burden, excessive pain, suffering, expense or other serious inconvenience to the person or to those who are responsible for their care. The principle is often expressed in terms of treatment being ordinary/extraordinary, proportionate/disproportionate, beneficial/non-beneficial, etc.

2. Double effect reasoning - Some human actions have both a beneficial and a harmful result, e.g., some pain treatment for a terminally ill person might carry a possibility of shortening life, even though it is given to relieve pain and is not intended to kill the person.

Five conditions are cited for trying to decide if such actions would be morally permissible:

  1. The action of the person must be morally good or at least neutral in itself.
  2. There are two anticipated outcomes for the action of the person, one intended and good, the other an unintended but foreseen evil.
  3. The evil effect is not the means to the good effect.
  4. There must be a proportionate reason to accept the evil effect.
  5. There must be no less-negative alternative.

3. Totality and integrity - A part of the body may be sacrificed to save the whole. For example, an organ may be sacrificed if it is the only way to prevent the death of the person. The moral tradition of the Church provides safeguards to protect against causing unjustified harm. The principle of totality points to a safe exception to the principle that one may not cause harm. Because the good of the whole is greater than the good of the part, it is justifiable to sacrifice the part for the whole. The Catholic tradition has limited the application of this principle to cases where the only function of the part is to serve the whole. For example, the eye has no function apart from being part of a living body. The tradition does not allow the principle of totality to be applied indiscriminately when the part has a proper function apart from the whole, as is the case of persons, who besides serving the state of which they are a part also have a value as individuals.

4. Subsidiarity - Decisions and functions ought to be handled by the smallest, lowest or least centralized competent authority.... As applied to health care needs, the principle suggests that the first responsibility for meeting these needs resides with the free and competent individual. Individuals, however, are not completely self-sufficient. Usually, they can achieve health and obtain health care only with the help of their family members, their caregivers and the community. The responsibility of fulfilling those needs that the individual cannot achieve alone must be assumed by larger or more complex groups, e.g., community organizations and different levels of government, without resorting to "micro-managing," which is contrary to the principle of subsidiarity.

Many years ago, while being interviewed by Bishop Sherlock as part of his search for a new Seminary Rector, he asked me - "Can you think of any quality that you have that these other priests might not have?" I said "No, they are all smarter than I am." But then, I added: "All I know is that I can make tough decisions and sleep well at night, but I don't want the job." I got it anyway!  

☩ Frederick Henry
Bishop Emeritus

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