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The Announcement of Death to St. Fina |
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The Announcement of Death to St. Fina |
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ONLINE RESOURCES: Caring for The Whole Person (L.A. Archdiocese); End of Life Care;
Catechism-Life [USCCB] ; ERDs [pdf ] ; The Good Samaritan [Vatican DDF]
Conference Handout: DOC-format; PDF Format
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THE issue of pastoral care for those facing terminal or debilitating illness has been rendered much more complex by recent legislation (June 9, 2016; amended 2021) that permits physician-assisted suicide in the State of California. It has always been the case that legalization of practices that were formerly forbidden both reflects changing cultural norms and is invariably accompanied by social pressure to “normalize” the now-legal practice.
THE issue of pastoral care for those who intend to take their own lives has been specifically addressed by the Dicastery for the Doctrine of the Faith in the September, 2020, document, Samaritanus Bonus / The Good Samaritan.
REQUIREMENTS
UNDER
CALIFORNIA
LAW
“CALIFORNIA
END
of LIFE
OPTION
ACT”
(Approved Oct 5, 2015, Effective June 9, 2016; amended 2021)
• Adult / California Resident
• Terminal illness: (Prognosis of 6 months or less)
• Mentally capable of making informed medical decisions (has capacity)
• Able to self-ingest lethal medication
[now-deleted] Summary by: The California Board of Registered Nursing
What does the new California law do?
The law authorizes a resident of California
who is 18 years of age or older,
who has been determined to be terminally-ill
and has capacity,
to make a request for a drug prescribed for the purpose of ending his or her life.
What safeguards are included in the law?
The Act includes several safeguards, which are aimed at restricting access to patients who are terminally-ill and mentally-competent:
· Two physician assessments are required. The “attending” and “consulting” physicians must each independently determine that the individual has a terminal disease with a prognosis of six months or less, and is able to provide informed consent. Elements of informed consent, including disclosure of relevant information, assessment of decisional capacity and assurance of voluntariness, are stipulated in the law.
· If either physician is aware of any “indications of a mental disorder,” a mental health specialist assessment must be arranged to determine that the individual “has the capacity to make medical decisions and is not suffering from impaired judgment due to a mental disorder.”
· The attending physician must provide counseling about the importance of the following: “having another present when he or she ingests the aid-in-dying drug, not ingesting the aid-in-dying drug in a public place, notifying the next-of-kin of his or her request for the aid-in-dying drug, participating in a hospice program and maintaining the aid-in-dying drug in a safe and secure location.”
· The attending physician must offer the individual the opportunity to withdraw his or her request for the aid-in-dying drug at any time.
· The individual must make two oral requests, separated by a minimum
of fifteen days, and one written request for the aid-in-dying drug.
[Changed Oct, 2021 to two oral requests a minimum of 48 hours apart]
· The written request must be observed by two adult witnesses, who attest that the patient is “of sound mind and not under duress, fraud or undue influence.”
· The patient must make a “final attestation,” forty-eight hours before he or she intends to ingest the medication.
· Only the person diagnosed with the terminal disease may request a prescription for the aid-in-dying drug (i.e., surrogate requests are not permitted).
· The individual must be able to self-administer the medication.
What are the documentation and reporting requirements?
The law explicitly stipulates a number of requirements for documentation in the patient’s medical record, largely corresponding to the safeguards above. In addition, the law creates two reporting obligations:
1. Within 30 days of writing a prescription for an aid-in-dying drug, the attending physician must submit to the California Department of Public Health (CDPH) a copy of the qualifying patient’s written request, an attending physician checklist and compliance form, and a consulting physician’s compliance form.
2. Within 30 days following the individual’s death, the attending physician must submit a follow-up form to CDPH. All forms will be posted on the CDPH and Medical Board websites.
Is participation required?
No. Participation in the law is voluntary for all parties. Individual providers -- and institutions as well -- may make personal, conscience-based decisions about whether or not to participate.
[Changed, Oct 2021 - Physicians who do not wish to participate are required to:
inform the individual seeking an aid-in-dying medication that they do not participate, document the date of the individual’s request and the provider’s notice of their objection, and transfer their relevant medical record upon request.
Senator Susan Eggman (D) introduced an amendment to California’s law, End of Life, SB380. Effective beginning January 1, 2022, the amendment:
• Reduces the waiting period between the 1st and 2nd oral request from 15 days to 48 hours;
• Eliminates the final attestation form;
• Requires physicians who cannot or will not support patient requests to tell the patient they will not support them, document the patient’s request and provider’s notice of rejection in the patient’s medical record, and transfer the relevant medical record upon request;
• Prohibits a health care provider or health care entity from engaging in false, misleading, or deceptive practices relating to their willingness to qualify an individual or provide a prescription for an aid-in-dying medication to a qualified individual;
• Requires health care entities to post their current policy regarding medical aid in dying on their internet website;
• Extends the law’s repeal clause to January 1, 2031.
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“THIS
is a challenge to all of us. Especially to all of us who have faith,” [...]
“to teach always about the infinite value of each human life.”
“THIS is a failure of our love, A failure of heart, really, that we can’t think of anything else we can do for people who have been told that they have terminal illness than to offer them a package of pills, where they can take their own life, and say, ‘Go ahead; just commit suicide.’”
[With regard to the effect of this law on the poor: ]
“IN our hospitals, it is the poor who are being advised and counseled more and more towards abortions [...] “Now it’s going to happen, also, I’m sorry to say, with the elderly, the most poor and most vulnerable.”
Bishop David O'Connell,
Mass at Santa Teresita Hospital,
June 1, 2016
WHY
DO PEOPLE
REQUEST
PHYSICIAN-ASSISTED
SUICIDE?
IN
THE PAST, (THROUGH the 1990s) THE MOST COMMON
REASON for REQUESTS for PHYSICIAN-ASSISTED-SUICIDE was
PAIN or
FEAR of
PAIN;
but by 1997 other motives were beginning to emerge.
From a 1997 Article in the New England Journal of Medicine:
[Competent Care for the Dying Instead of Physician-Assisted Suicide, Kathleen M. Foley, M.D., N Engl J Med 1997; 336:54-58 January 2, 1997 Editorial, DOI: 10.1056/NEJM199701023360109]
Pain, AIDS, and neurodegenerative disorders are the most common conditions in patients requesting assistance in dying. There is a wide range in the age of such patients, but many are younger persons with AIDS.10 From the limited data available, the factors most commonly involved in requests for assistance are[:]
[1] concern about future loss of control,
[2] being or becoming a burden to others,
[3] or being unable to care for oneself and fear of severe pain.10
A small number of recent studies have directly asked terminally ill patients with cancer or AIDS about their desire for death.25-27 All these studies show that the desire for death is closely associated with depression and that pain and lack of social support are contributing factors.
10. Back AL, Wallace JI, Starks HE, Pearlman RA. Physician-assisted suicide and euthanasia in Washington State: patient requests and physician responses. JAMA 1996;275:919-925
25. Brown JH, Henteleff P, Barakat S, Rowe CJ. Is it normal for terminally ill patients to desire death? Am J Psychiatry 1986;143:208-211
27. Breitbart W, Rosenfeld BD, Passik SD. Interest in physician-assisted suicide among ambulatory HIV-infected patients. Am J Psychiatry 1996;153:238-242
BY 2012 THE CHIEF REASONS for REQUESTS had SHIFTED to
FEAR of THE LOSS of AUTONOMY
From a 2012 Article in the New England Journal of Medicine:
[Julian J.Z. Prokopetz, B.A., and Lisa Soleymani Lehmann, M.D., Ph.D. N Engl J Med 2012; 367:97-99 July 12, 2012, Perspective DOI: 10.1056/NEJMp1205283]
Advances in palliative medicine have produced effective strategies for managing and relieving pain for most terminally ill patients, including the possibility of palliative sedation. Inadequate pain control therefore ranks among the least common reasons that patients in Oregon request lethal medication. Most say that they are motivated by[:]
[1] a loss of autonomy
[2] and dignity
[3] and an inability to engage in activities that give their life meaning.2
Patients in the United States may already decline to receive life-sustaining treatment through advance directives, but that is a reactive stance: only when an acute condition occurs can patients decline intervention, and many patients have no life-sustaining treatments to withdraw. Some terminally ill patients wish to exercise their autonomy and control the timing of their death rather than waiting for it to happen to them.
2. Thirteenth annual report on Oregon’s Death with Dignity Act. Portland: Oregon Office of Disease Prevention and Epidemiology, 2010.
Pope
St John Paul II on Palliative Care (2004);
END
of LIFE CARE (L.A.
Archdiocese)
Interviewing a Hospice Agency (LA Archdiocese:)
[local]
PALLIATIVE CARE describes the treatment of symptoms, usually pain and psychological distress associated with illness, rather than an attempt to cure the underlying illness. At the end of life palliative care is generally called “HOSPICE”; however palliative medicine will play an increasingly-important role in the practice of medicine in all stages of life as advances are made in methods of controlling pain and alleviating symptoms of chronic and incurable diseases.
THE Catholic Church encourages and recommends palliative care as an important and unselfish kind of love, “a special form of gracious [disinterested] charity” (Catechism §2279: formam constituunt excellentem caritatis gratuitae). Pope St. John Paul II echoed this in a 2004 address on Palliative Care.
The Dicastery for the Doctrine of the Faith encourages palliative care (Samaritanus Bonus V.4) and has clarified that is morally acceptable for persons facing the end of life to obtain treatment that renders them unconscious (“deep palliative sedation in the terminal stage”): Samaritanus Bonus V.7.
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The following summary was kindly provided by a physician who specializes in palliative care and practices in Southern California
PATIENTS and families are often surprised that hospice and home-based palliative care do NOT provide 24/7 care for anyone.
● Routine hospice care may include a couple of half days a week for a bath aide plus skilled nursing visits (typically in 2 hour increments at least once weekly) for medication management, wound care, catheter management, etc.
●
The most that HOSPICE can provide is “continuous care” at home in 4 hour increments [and renewable in 4 hour increments] for patients in crisis.● There is an in-patient hospice benefit that can keep a patient in a facility for a few days (typically during a crisis or at the very end of life)
● There is also a RESPITE benefit of a few days of facility-based caregiving
● There are VOLUNTEER companions that may be available to sit with patients for a few hours while family is away or resting
● There are community-based residential non-profits (many originating from the AIDS crisis of the 80s and 90’s) that provide no-cost or sliding-scale care for weeks or months at the end of life [e.g.: the Zen Hospice in San Francisco.]
● Hospice and Palliative Care in the United States is mostly F
OR-PROFIT and provide charity care as a community service subsidized by their paying patients [note that LIVINGSTON MEMORIAL VNA and HOSPICE in Ventura County is a non-profit operation
When an uninsured patient shows up [typically in the ER setting with catastrophic illness] it is hospital case management that gets involved. The hospital assumes the cost of unreimbursed care. Sometimes, emergency Medi-Cal can be obtained to cover the cost of (some) services. Nursing facilities and Residential facilities will not accept these patients without a payment source and they end up staying in the hospital, being transferred to a county hospital, or returning home and cycling in and out of the ER. Non-hospital care is provided for the uninsured by a network of free clinics that are funded by state, local and private grants.
Home-based caregiving is not a covered benefit for anyone in this country except for persons who purchased a long-term care insurance policy. Even for those patients, criteria to activate the benefit is highly restrictive and there is typically a “waiting period” of 100 days before the benefit begins to pay out. Home health nursing benefits provide intermittent/episodic care to meet defined medical needs and do not provide caregiving as part of their services.
The counties in California have an In-home Supportive Services [IHSS] benefit that pays for a limited amount of care for patients on Medi-Cal. Application and activation of benefits can take up to 6-8 weeks. Typical awards are for less than 100 hours a month.
There is also a limited State benefit for employees needing time off to assist in the care of a qualifying family member. Information at https://edd.ca.gov — search term paid family leave for caregivers
FOR many centuries the Catholic Church has taught what is now clearly stated in the Catechism of the Catholic Church with regard to withdrawing or withholding medical treatment and how to apply the traditional categories of horror vehemens and “moral impossibility”.
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§2278. Discontinuing medical procedures that are [:] |
2278 Cessatio a mediis medicinalibus, |
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burdensome, dangerous, extraordinary, or disproportionate to the expected outcome |
onerosis, periculosis, extraordinariis vel talibus quae cum effectibus obtentis proportionata non sunt, |
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can be legitimate; it is the refusal of “over-zealous” treatment. Here one does not will to cause death; one’s inability to impede it is merely accepted. The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected. |
legitima esse potest. Haec est recusatio « saevitiae therapeuticae ». Hoc modo, non intenditur mortem inferre; accipitur non posse eam impedire. Decisiones suscipiendae sunt ab aegroto, si ad id competentiam habeat et capacitatem, secus autem ab illis qui ad id, secundum legem, habent iura, rationabilem aegroti voluntatem et legitimum commodum semper observantes. |
THESE issues are also discussed in the the USCCB-ERDs (Part Five - Issues in Care for the Dying); and in Christ the Good Samaritan V.2.
SOME confusion arose in 2004 through misinterpretation of an Address on the Persistent Vegetative State by Pope Saint John Paul II (March 20, 2004); however, this was clarified in his Address on Palliative Care (November 12, 2004).
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Saints Cosmas and Damian perform
a Limb-Transplant |
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THERE exists a widespread misconception that the Catholic Church requires the bodies of deceased persons to remain in tact whenever possible, and that organ-donation is thus opposed to Catholic tradition. This is completely false. Pope Saint John Paul II proclaimed that organ donation is a heroic action and a particularly praiseworthy example of the gift of self. Evangelium Vitae, 86. This teaching is reiterated in The Catechism of the Catholic Church §2296, and the USCCB Ethical and Religious Directives §63-64.
THE Catechism of the Catholic Church and all recent magisterial documents concerning health care have reaffirmed Pius XII's declarations concerning the necessity of free, informed consent for medical procedures.
THE THE priest-chaplain, relatives and friends can all play an essential role by insuring that informed consent has actually taken place, since patients and decision-makers frequently hear what they want to hear, rather than what their physician has told them
ADVANCE DIRECTIVES are essential for everyone - not only those who are hospitalized or seriously ill.
ADVANCE
HEALTHCARE
DIRECTIVE
(English):
https://lacatholics.org/wp-content/uploads/2020/01/Advanced-Healthcare-Directive.pdf
ADVANCE
HEALTHCARE
DIRECTIVE
(Spanish):
https://lacatholics.org/wp-content/uploads/2020/01/Advance-Health-Care-Directive-Spanish.pdf
POLST: Intention in Law and Catholic controversy (bishops - nav.)
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DDF Samaritanus Bonus (Vatican) ; Interviewing a Hospice Agency (LA Archdiocese:) [local]
WITH regard to palliative care/hospice agencies, it is important to ask:
1. Does the agency offer Physician-Assisted Suicide (“Medical Aid in Dying”) as one of the services they provide? (e.g. City of Hope pdf)
2. If so, how do they respond to patients and surrogate decision-makers who regard “Medical Aid in Dying” as immoral?
WHEN someone we love, or for whom we are responsible raises the question of Physician Assisted Suicide, the following are important:
1. LISTEN: encourage the person to speak freely before you comment.
2. Obtain as much INFORMATION as possible.
3. Avoid emotionally-charged or judgmental language.
4.
DISCOVER
WHY the person is considering suicide: what do
they fear?
(e.g. Dependency; Physical Linitation; Isolation; Pain.)
5. Help the person clarify their
INTENTION: What do they really
desire?
(e.g.: Not to be a burden; Not to be dependent; Not to be alone; Not to be in
pain.)
6. SUGGEST alternatives: Address the underlying reasons for the person's request.
7. ONLINE RESOURCES
L.A. Archdiocese: “Caring for The Whole Person” https://lacatholics.org/caring-for-the-whole-person/
L.A. Archdiocese: “End of Life Care”: https://lacatholics.org/end-of-life-care/
Advance Healthcare Directives: English (PDF) \\ Spanish (PDF)
Interviewing a Hospice Agency: Questions to Ask
Catholic End of Life Teachings; (En Español)
End of Life Decisions Pastoral Guide; (En Español)
Hospice and Palliative Care; (En Español )
Frequently Asked Questions About End of Life
Transformed By Love: Consider Your Spiritual Care at the End of Life – Archdiocese of Washington
Transformed By His Gaze: Coping with Grief – Archdiocese of Washington
Comfort & Consolation: Questions to Consider Now & At the Hour of Our Death
Catechism of the Catholic Church (Life Issues) §2258-2301: https://www.usccb.org/sites/default/files/flipbooks/catechism/ ”.
USCCB “Ethical and Religious Directives,”6th ed., 2016: https://www.usccb.org/about/doctrine/ethical-and-religious-directives/upload/ethical-religious-directives-catholic-health-service-sixth-edition-2016-06.pdf
Pope Saint John Paul II, Encyclical “Evangelium Vitae, 1995 https://www.vatican.va/content/john-paul-ii/en/encyclicals/documents/hf_jp-ii_enc_25031995_evangelium-vitae.html
Pope Saint John Paul II Address [on Palliative Care], 2004: https://www.vatican.va/content/john-paul-ii/en/speeches/2004/november/documents/hf_jp-ii_spe_20041112_pc-hlthwork.html
Congregation for the Doctrine of the Faith “Iura et Bona (Declaration on Euthanasia),” 1980: https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19800505_euthanasia_en.html
Dicastery for the Doctrine of the Faith, “Dignitatis Personae, On Certain Bioethical Questions,” 2008: https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_20081208_dignitas-personae_en.html
Dicastery for the Doctrine of the Faith, “Christ the Good Samaritan,” 2020: https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_20200714_samaritanus-bonus_en.html
This Webpage was originally created for a workshop held at Saint Andrew's Abbey, Valyermo, California in 2003
