Moral issues make some advance directives better than others
April 18, 2019
How can I ensure my wishes concerning medical treatment will be honored if I’m unable to speak for myself, especially if I’m seriously ill or approaching death? Can I be confident those choices will reflect God’s will for me? And how can I make sure all relevant information is considered when those decisions are made?
Seniors and their loved ones are increasingly asking such questions as the twilight of life approaches, especially in difficult circumstances marked by advances in technology, higher medical costs and the dehumanization of medicine. And caregivers, among others, are seeing to it that they get answers.
New Cassel Retirement Center in Omaha, for example, helped about 30 residents and family members explore a range of end-of-life issues during the center’s Education and Resource Fair, marking National Healthcare Decisions Day, April 16.
The program provided information about advance directives, hospice care, legal and financial concerns, long-term care insurance and funeral pre-planning.
Colleen Mayo, whose mother lives at New Cassel, attended to learn about end-of-life decision-making.
“My family is very spiritual, so it’s important to be able to make decisions in line with church teaching while also respecting mom’s wishes,” said Mayo, a member of St. James Parish in Omaha. “And sometimes it’s a fine line – at what point does giving food become ‘extraordinary’ means?”
Her mother, Mary Kusek, who moved to New Cassel from Grand Island in 2016 to be closer to family, established a health care power of attorney to guide her family on medical choices should she become unable to make them.
This is the best form of advance health care directive, said Joe Zalot, a staff ethicist with the National Catholic Bioethics Center in Philadelphia.
Compared to a “living will,” which spells out in advance a person’s wishes concerning certain health care decisions, a health care power of attorney, or HCPOA, designates a trusted person to whom decision-making authority is granted, should a person be incapacitated and unable to make those decisions.
“We recommend that everyone should have a health care power of attorney; a living will … not so much,” Zalot said.
“We prefer in-the-moment decision making. If you’re going to make health care decisions, which are moral decisions, you have to have all possible information. What living wills do is ask people to make future medical decisions when they have no idea what their future condition is going to be,” he said.
A similar problem exists with Physician Orders for Life Sustaining Treatment (POLST), which spell out, in advance, to a physician or other health care provider, specific treatments one wants during a medical emergency.
Marion Miner, associate director for pro-life and family with the Nebraska Catholic Conference (NCC), argues that POLSTs are problematic.
“They are binding on all doctors – not just the doctor who signed the document or the doctors in that hospital – even years down the road, Miner said, and typically override any existing health care power of attorney or other advance directive that the patient has filled out.”
Miner said the NCC, which also recommends a HCPOA, provides guidelines for creating one according to church teaching on its website, necatholic.org. These include never acting or failing to act with the purpose of causing death.
“The Catholic Church has always and will always uphold the dignity and worth of human life by vigorously opposing assisted suicide and euthanasia,” he said. “But it recognizes and teaches that in instances where continued medical intervention would be excessively burdensome – due to pain or expense relative to the likelihood of success – a person or his caretaker is not obligated to continue that treatment.”
The church also teaches that unresponsive patients must be given food and water, through artificial means if necessary, as long as the patient is able to assimilate that nutrition and death is not imminent. And patients also must be given all other means of ordinary care, such as making sure the person being treated is warm, clean, and is not neglected, Miner said.
Zalot said, “Make sure you understand what the church teaches, and use that knowledge to formulate your values and wishes, and then convey those to the person who is going to be making those decisions.”
DO NOT RESUSCITATE
Another advance directive is a do not resuscitate order (DNR), he said. A DNR indicates that the person does not wish to be resuscitated in the event of cardio-pulmonary arrest.
“The church doesn’t have a specific teaching on DNRs, but for most of us a DNR would not be appropriate,” he said. “It can be appropriate if someone is in the final stages of a terminal illness, or is elderly and quite frail.”
A New Cassel resident for whom a DNR was appropriate was Emily Driscoll, a 90-year-old who died suddenly several weeks ago of a heart attack, said her niece, Liz Sambol, a member of St. Robert Bellarmine Parish in Omaha.
“She had a heart attack about five years ago and had coronary disease and had a DNR in place; she died exactly the way she wanted to,” Sambol said. “She wanted to die a natural death with no extraordinary means being used.”
Driscoll, who was a nurse for 50 years, also had pre-arranged for her body to be donated to medical science, Sambol said. “She went through the Nebraska Anatomical Society to donate her body and signed the papers ahead of time. So all I had to do was call the number on the papers, and they took care of everything,” Sambol said.
Good, early communication is key when helping an older person make decisions about advance directives, Sambol said. Although her aunt did not have an official HCPOA, Sambol understood her wishes.
“You need to slowly begin talking to them in advance, before the person becomes sick, so you can make sure as many wishes as they have can be followed through.”