By Michael McCarthy
Matthew’s Gospel offers several narratives that center on Jesus’s healing ministry. While the miracle narratives center typically on the wonder of the miracle, for those in healthcare ministries they also create an opportunity to reflect on the finitude of life, the challenges presented by illness, and the wisdom within the Catholic tradition for discerning a patient’s choices when treating a serious illness near the end of life. The Ethical and Religious Directives (ERDs) serve as a helpful resource that emphasizes the importance of advance care planning, articulates how the Catholic tradition envisages decision-making and provides a rationale for not offering treatments that go against Catholic teaching.
There are essentially three forms of advance care planning: a living will, health care power of attorney form, and a physician order for life-sustaining treatment. POLST may be the least well known, and has received some critique in Catholic commentaries.
One critique of the POLST centers on the seeming permanence of an order made prior to knowing the specific context in which end of life wishes are carried out. Thus, is a patient prematurely refusing treatments without knowing the ramifications of that decision? Secondly, there is concern that the physician might not have enough information about the patient and is following an abstracted process. Tom Narin, the former senior ethicist at Catholic Health Association, acknowledges that the form is not perfect, but appreciates the way that the POLST initiates further conversation on advance care planning. It brings the patient’s physician into care planning, and seems most appropriate around a serious diagnosis. The form need not replace conversations with family and written down in a living will.
The second form of advance directive is the living will, which proves helpful if a patient loses the capacity to make decisions. Capacity is determined by physicians based on the ability to communicate a choice; understand the information and appreciate its significance or consequences; and reason about treatment options. If a patient does not have capacity, the living will offers a clear statement of the patient’s wishes regarding what life-sustaining treatments he or she would find appropriate.
Finally, the healthcare power of attorney form indicates patient preferences based off a standard checklist and identifies an individual to serve as the legal decision-maker if the patient loses capacity or would prefer that someone else make healthcare decisions. It ensures that there is a person whom the patient has talked to about preferences for treatment options. The role of the POA is to act according to the patient’s wishes, not the POA’s wishes. Absent of the patient’s known wishes for a particular decision, the POA may make decisions according to “substitute judgment” or “best interest.” While the best interest standard weighs the benefits and burdens of a particular treatment, substitute judgment makes the decision as if the POA was the patient. This decision requires thinking through values that the patient held or conversations that the POA and patient may have had in order to make the decision as if the patient were deciding. Chaplains can play an important role in listening and talking to patients, POAs, and family members about the patient’s values and wishes.
The ERDs both encourage advance care planning and offer a moral framework for what constitutes reasonable healthcare decisions at the end of life in the Catholic tradition. Directives 24 and 25 encourage advance planning that is mindful of patient’s preferences and values, while being informed by the Catholic tradition. The Catholic tradition emphasizes ethical decision making that is informed by the medical facts, respects the dignity of the patient, and balances the benefits and burdens of treatment options. Patients are not required to pursue treatments that do not offer “a reasonable hope of benefit” or that “entail an excessive burden, or impose excessive expense on the family or the community” (ERD, 57). While a patient rarely requests a treatment that goes against the ERDs, it can happen. These requests may become more common in states in which physician-assisted death is legal.
In a Catholic institution, it can be difficult to inform a patient or family that such a choice is not available because it is against Church teaching. But it is important to be aware of patient preferences and listen to the patient’s or POA’s perspective, reflecting back the values you hear guiding the medical decisions. Often patients will cite concerns about losing independence, being a burden, or fear of pain and suffering. While all of these are reasonable fears, chaplains may be able to reflect on these concerns with the patient and help her consider hospice or palliative care as an alternative. Engaging family members or a patient’s pastor or religious leader may also be helpful. Discussing the ERDs and the guidelines that prohibit participation in physician-aided death is especially helpful if working at a Catholic institution. Finally, it is important to discuss the patient’s wishes with the healthcare team and/or a member of the ethics consultation service, in case a transfer of care is necessary.
While physician-aided death is not available in a Catholic institution, chaplains may find themselves working with patients in a secular context where it is. In this instance, a chaplain should listen to the patient and accompany them as far as their conscience allows, but ought not to facilitate making it more easily accessible. If a patient asks what a chaplain thinks about physician-aided death, try to offer the guidance of the ERDs regarding life as a gift, the dignity of the all human beings, and the difference between extraordinary and ordinary means of care. These options allow Catholic chaplains to draw from the tradition, distilled into the ERDs. Even outside the walls of Catholic institutions, the ERDs serve as a concise representation of moral tradition that can inform the conscience of both Catholic chaplains and patients.
As in Matthew’s Gospel, many patients and families hope for a miracle without recognizing important decisions that need to be made. While no one wants to take that hope away, the Catholic tradition recognizes the finitude of life, and advance directives can ensure decisions that reflect the patient’s wishes and values. Patients arrive daily at the hospital without having talked about the end of life, which may result in treatment options that they would not have wanted. The ERDs serve as a resource for families and patients as they begin to plan for life’s inevitable end.
Michael McCarthy, PhD, is an assistant professor at the Neiswanger Institute for Bioethics at Loyola University Chicago.
