With New End-of-Life form, Catholic Healthcare Seeks to Strike Balance

Andrew Kitchenman | September 16, 2013 | Health Care, Social
Catholic leaders in NJ don’t see conflict, but other bishops and ethicists warn against distribution of advanced directive

St.Joseph’s Healthcare System President and CEO William A. McDonald and New Jersey Hospital Association President Betsy Ryan
A new form intended to guide end-of-life healthcare decisions is forcing Catholic hospitals and nursing homes to take a position on a contentious ethical issue, but New Jersey church leaders appear to be having an easier time supporting the form than those in other states, where Catholic bishops and ethicists are battling it.

For example, St. Joseph’s Regional Medical Center in Paterson is encouraging patients who may be in the last year of their lives to talk with their families and doctors about the Practitioner Orders for Life-Sustaining Treatment (POLST) form.

The form offer patients an opportunity to list their goals for care and give their preferences for medical interventions, artificially administered fluids, and nutrition and cardiopulmonary resuscitation. It is similar to an advance directive, but unlike those documents it has the force of a doctor’s order and must be followed by other healthcare providers.

The subject of end-of-life care focusing on the POLST was discussed by a panel of healthcare experts at St. Joseph’s on Friday.

While Catholic leaders in the state said they believe the form complies with the church’s ethical and religious directives for healthcare, bishops in Wisconsin and Minnesota, as well as a paper published in a national Catholic bioethics journal, have criticized similar forms for conflicting with Catholic teaching. They say the forms are signed too early, opening up the possibility that they will lead doctors not to provide the nutrition and fluids the church regards as part of required treatment.

The issue is a sensitive one for the church, which has fought prominent battles over the amount of care required for some gravely ill patients. And with an estimated 42 percent of state residents considering themselves to be Catholics, the church’s position could have a major impact on the adoption of the form, which is being encouraged by state healthcare leaders.

Sister Pat Codey, president of the Catholic HealthCare Partnership in New Jersey, served on the 15-member New Jersey Hospital Association steering committee that wrote the form based on a 2011 law signed by Gov. Chris Christie.

She said the language used on the form is in accordance with church healthcare directives. Her organization is a coalition of Catholic healthcare providers.

“It’s a universal form that should be accepted by all,” Codey said, adding that all residents will use their values and beliefs “as a framework to make decisions about your life.”

The forms used in other states were criticized in a paper recently published by Linacre Quarterly, the bioethics journal of the Catholic Medical Association (CMA), a national doctors’ group.

John Brehany, an author of the paper and the CMA president and ethicist, said medical decisions are best made based on the specific circumstances that a patient faces, which a form signed months ahead of time cannot take into account.

“To the extent that you create a form that substitutes for good medical judgment, that might be highly problematic,” said Brehany, whose organization is based in Bala Cynwyd, Pa.

Brehany said these judgments should be made at the “right time.” He said the state law introducing the form was too vague. The law said the form is intended for patients “who have advanced chronic progressive illness or a life expectancy of less than five years, or who otherwise wish to further define their preferences for healthcare.”

Brehany said this would allow the form to be filled out when the patient doesn’t know the circumstances of a health emergency that could present a unique set of ethical issues.

“Look at the way society’s going: ‘We’re going to get some form and the form’s going to save us, right? We can input a decision and things are going to work more smoothly,’ ” Brehany said. “That’s not the way things work at the end of life.”

Some of the ethicists’ concerns focus on how nutrition and water are provided to seriously ill patients. The paper cites a 2004 statement by Pope John Paul II, in which he said that nutrition and hydration, even by artificial means, should be considered “morally obligatory.” Some church officials are concerned that the POLST would prevent doctors from providing a form of nutrition — such as a feeding tube — that the church would normally considered necessary.

Patrick R. Brannigan, executive director of the New Jersey Catholic Conference, said the POLST could be considered an extension of advance directive, a version of which the conference encourages to be used.

“To the best of my knowledge there appears to be no conflicts between the New Jersey POLST law and Catholic teaching on end-of-life issues,” Brannigan wrote in an email.

The New Jersey POLST form allows patients to choose one of three options regarding artificially administered fluids and nutrition: “no artificial nutrition,” “defined trial period of artificial nutrition,” and “long-term artificial nutrition.”

A church directive regarding nutrition and hydration may provide guidance for answering this question. While this directive says: “in principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally,” it also says, “as a patient draws close to inevitable death from an underlying progressive and fatal condition, certain measures to provide nutrition and hydration may become excessively burdensome and therefore not obligatory in light of their very limited ability to prolong life or provide comfort.”

Codey noted that if a Catholic institution found that a patient’s wishes conflicted with church directives, the directives “would prevail and therefore you would need to transfer that person to a facility where that person could be accommodated and their wishes respected.”

St. Joseph’s Healthcare System President and Chief Executive Officer William A. McDonald said the hospital is actually in a stronger position to implement the POLST form because of its Catholic heritage.

St. Joseph’s “is really unique in its focus on taking care of the patient, not just the physical needs of the patient, but the mental as well as the spiritual needs of the patient,” McDonald said.

Hospital officials said St. Joseph’s led the state in integrating palliative care into its emergency department. In this form of care, the focus of treatment is on relieving symptoms rather than curing disease.

Hospital Emergency Services Chairman Dr. Mark Rosenberg said as soon as any patient who may be terminally ill enters the emergency department, they are consulted about palliative-care treatment options. If they don’t already have a POLST, hospital staff members help arrange for patients to talk with their primary care doctors and family members about the form.

State Health Commissioner Mary E. O’Dowd, who led the panel discussion gave several reasons why patients can benefit from having the form. They include offering the chance to make their wishes clear before they are in an emergency situation. She noted a study by the Dartmouth Atlas that New Jersey leads in the nation in spending and medical specialist visits in the last two years of life.

“That would be OK if it was correlated with an improved outcome or improved quality, but it is not,” she said.