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Life, Life Support, and Death
Wednesday, October 5, 2005 - By Paul Byrne

Principles, guidelines, policies and procedures for making decisions that respect life

Some aspects of the euthanasia movement are clear, but many others are subtle and the truth is not easily discerned. There is a paucity of truthful education regarding "brain death," death with dignity, living wills, and death by dehydration and starvation. All in society, especially physicians and all health care personnel, must become as familiar with these topics as they are with abortion. Abortion is just the tip of the euthanasia movement.

While most articles appearing in the medical literature have supported a public policy that would inarguably lead to the deaths of many of our patients, some good has resulted from this cacophony. All physicians, including those who support the principles detailed here, have been called to remember the dictum of Francis Peabody that "the secret of the care of the patient is in caring for the patient."[1] The most essential ingredient required to accomplish this goal is two-way communication with the patient and his or her family. Beginning with the first visit of adults, the doctor must strive to establish that kind of rapport that allows for an under-standing of the responsibilities, obligations and duties of the patient himself or herself. Other medical personnel must also be involved in establishing such rapport.

The topic of "brain death" has been pursued for more than 15 years by Dr. Paul Byrne; Dr. Joseph Evers; Dr. Richard Nilges; the late Dr. Sean O'Reilly; Fr. Paul Quay, S.J.; Attorney Peter Salsich; and others.[2] The understanding and insight that have been gained about the immorality of the use of the current criteria for "brain death" make it easier to take a stand against killing that is done by withdrawing or withholding food and water, and/or giving a lethal injection.

We see a young, strong, vigorous man slam-dunk a basketball. Within seconds of all that activity, he collapses and then dies. He was surrounded by persons trained to do CPR (cardiopulmonary resuscitation). Let's presume that everyone administered "all the best" that medicine had to offer. Still he died. The reality is that treatment does not always succeed at keeping a patient alive.

Some treatments and therapies are helpful and do result in a patient's living longer (e.g., a cardiac pacemaker). When a disease is lethal and there are multi-organs or multi-systems involved, the prognosis is often not good. Patients do die even while a ventilator is continued. At that time everyone can observe and know that death has occurred, even though the ventilator continues to move air into and out of the chest.

What approach should be taken by a physician and others regarding the use or non-use of medical care or the use or non-use of a ventilator? How should the dying patient be treated? When has death actually occurred? How should a patient's relatives consider these issues? The answers are not simple. Every decision should be individualized, especially when life or death is at risk. The common law right of a competent patient to refuse medical treatment does not diminish the duty of the physician. Presented here are some principles, guidelines, policies and procedures that should be helpful to those making decisions.

The major premise

Let's begin with human life is sacred. Leon Kass has written in Commentary that "...life is in itself something holy or sacred, transcendent, set apart-like God Himself...[L]ife is something before which we stand (or should stand) with reverence, awe, and grave respect-because it is beyond us and unfathomable...[T]o regard life as sacred means that it should not be violated, opposed or destroyed, and, positively, that it should be protected, defended and preserved..."[3]

God alone is the Author of a person's life, and He alone may determine when a person's life will end. Since human life is a gift from God, there is a primary moral obligation to show reverence for that life at all times from its beginning until death. Any failure to show reverence for or to safeguard life is an attack on the individual patient, on others involved, on the medical profession, on society, and on God.[4]

No physician, nurse, other personnel or caregiver should participate in assisted suicide or euthanasia. By euthanasia, we mean an action or an omission which of itself or by intention causes death, in order that suffering may in this way be eliminated. No one should ever be deprived of basic care, including food and water, suitable bedding, an optimal thermal environment, a patent airway, exits for stool and urine, and available effective treatments and therapies. A hospital exists to diagnose and treat ill patients. While not every illness can be cured, every patient must be cared for. The object is always to provide the best available medical care to the whole person, physically, mentally and spiritually. To purposefully expedite death by omission or commission violates a fundamental principle of medicine-"First, do no harm." Recognizing that not every illness can be cured, but that every patient must be cared for, a hospital cooperates with other facilities and services, as well as the patient's family, to deliver the best care possible to the patient.

Without food and water

Withholding or withdrawing food and water leads only to death. Death by starvation and dehydration is a very undignified and inhumane death. It demeans the patient. The patient's mouth dries out and becomes coated with thick material. Lips become parched and cracked. The tongue swells and might crack. The eyes sink back into their orbits. The lining of the nose may crack and bleed. The skin becomes loose, dry and scaly. The urine concentrates, then decreases until there is no urine. The stomach lining dries, causing dry heaves. The respiratory tract dries out, giving rise to thick secretions which could plug the lungs and cause death. Eventually, major organs fail, including the lungs, heart and brain.

Methods of administering food and water include the customary method of self-feeding with utensils or fingers, and being fed or given a drink with a glass, a spoon or a straw. When a person has difficulty with swallowing, including an inability to swallow and/or the possibility of aspirating food into the airway, a nasogastric tube (plastic or rubber tube passed through the nose into the stomach) or gastrostomy (a tube going through the abdominal wall into the stomach, which can be done nowadays in a patient's room with minimal discomfort) is used to administer food and water. While a nasogastric tube uses an opening that is present naturally, it can be safer and easier for patients prone to aspiration to have a gastrostomy tube. Water and nutrition can be given directly into a blood vessel when medically indicated. The moral obligation to supply hydration and nutrition, even artificially if necessary, remains intact even when caring for patients in a coma or so-called "persistent vegetative state." Mental incapacitation does not relieve this responsibility. Withholding or withdrawing food and water is active euthanasia apart from the exceptional case where the method of administering food and water is gravely burdensome or requires heroic virtue, i.e., the method in itself is gravely burdensome in excess of the burdens already being experienced by the patient, or it renders the whole medical situation gravely burdensome. There is no moral obligation to obtain or to continue treatment that is gravely burdensome or would require heroic virtue.

Ordinary vs. extraordinary means

Decisions to use or not to use a treatment are often considered according to "ordinary" and "extraordinary" means. "Ordinary" and "extraordinary" means represent constructs by ethicists enabling an understanding of the decision by the patient himself/herself who elects to use or not to use a particular treatment. "Ordinary" means include any treatment, medication, or operation which offers a reasonable hope of benefit without requiring heroic virtue, i.e., above and beyond ordinary virtue, e.g., without causing excessive pain, expense, or other grave burden to the patient himself/herself. The patient has an obligation to use all available "ordinary" means to preserve his/her life. A physician may not encourage a patient to violate his or her obligations, help him/her to do so, or refuse a patient's request for a treatment that is obligatory.

"Extraordinary" means (or "disproportionate" means, as preferred by some in modern times) would require heroic virtue, or be gravely burdensome. Here we are emphasizing that it is the means, i.e., the treatment, medication or operation that is gravely burdensome or requires heroic virtue. We use strong language, i.e., gravely burdensome; others use excessively burdensome. Also, we use heroic virtue. We are not trying to be scrupulous, nor do we want others to be so. However, we do wish to imply the burden must be extremely great and the virtue required is beyond ordinary virtue. Although the patient is not obligated to use "extraordinary" means, he/she may decide to do so. Such a course could constitute an act of heroic virtue. An example of this might include some varieties of chemotherapy which could cause overwhelming malaise and fatigue so that the treatment would be worse than the disease from the patient's perspective. "Extraordinary" means cannot be withheld or withdrawn, however, in order to kill the patient or to advance other immoral ends. Moreover, medical progress may render today's "extraordinary" means tomorrow's "ordinary" means. An example of this is renal dialysis. This method of clearing the patient's blood of nitrogenous waste products and other toxins was unknown when several of the authors were in medical school. Today it is available in virtually all urban areas.

In the religious context in which "ordinary" vs. "extraordinary" means originated, "extraordinary" means are limited to particular criteria that may (not must) be employed by the patient himself/herself to ascertain his moral duty to utilize specific medical treatments. Withholding effective, supportive, and non-burdensome treatment because of a diagnosis of an irremediable illness cannot be construed as acceptable behavior within the ethical construct of ordinary/extraordinary means.

When the patient is unable to speak for himself/herself, the decision regarding treatment becomes more complicated. As a general rule in such a case, the physician must find out any wishes the patient had expressed previously. Then, the physician must obtain consent from a proxy. The instruction to the physician should be as close as possible to that which the patient himself/herself, if able, would have given. Almost always the patient has a close family tie with a spouse, a parent or a child. As a result of these bonds, when the patient is unable to communicate for himself/herself, the physician has an obligation to communicate with the family. Pertinent information from relatives and close friends is extremely helpful at these times. Communication with loved ones offers the best chance for personalize care for the patient unable to speak for himself/herself.

Decisions regarding health care must be current judgments based on current information. While one may have thoughts about how one would make a decision under a given set of circumstances, the decision actually must be made using current facts, including the state of the art of medicine, which is always being updated generally and locally. Thus, judgments must be current and based on current information. The necessity to use current information should be sufficient, in itself, to invalidate so-called living wills. While a "durable power of attorney" meets this requirement of access to current data, one must make certain that the philosophy of the durable power of attorney and the decision-making of the proxy designated under the durable power of attorney are consistent with the life principles and policies discussed herein. When the decision must be made and what the patient would want isn't known, one may have to make a judgment based on the patient's "best interest," always keeping foremost that human life is sacred and that life and the life span on earth are gifts from God, a span which must be determined only by God Himself.

When it is determined that a patient is dying of a lethal disease that is medically irremediable and it is predicted that death will occur within hours with or without treatment or therapy, the patient or the patient's proxy has the moral option to request or to refuse such treatment or therapy. (Here we use "hours" to avoid the term "imminent," because of overly broad medical/ legal interpretation of "imminent" to mean even up to one year.) The physician must be morally certain that he/she has done all in his/her power in accord with the wishes of the patient to help him or her live the life span given by God.

There is an obligation for the physician and the hospital to provide a treatment or therapy that is gravely burdensome when the patient wishes such. An example of a gravely burdensome treatment could include one that requires travel to a distant location in a very weakened condition to obtain said treatment.

When the patient is unable to communicate and it has been made known that the patient still has obligations to others which a gravely burdensome treatment or therapy could help the patient to meet, the physician should gently encourage its use. There is a similar obligation when the patient is unable to communicate and it has been made known that the patient's spiritual needs have not been met. In this circumstance the family and/or proxy should be involved with the hospital staff to provide for the patient's spiritual comfort.

Resuscitation-Life support

When it is directed by a dying patient or the patient' s proxy that a gravely burdensome treatment will not be administered, a specific order for that specific non-treatment must be written. Written orders must be as precise as possible. "Do Not Resuscitate" or "No Code" are examples of ambiguous orders widely accepted by physicians and courts. Do these orders mean no maintenance of an airway, or no ventilation, or no cardiac resuscitation, as well as no new or additional therapy? Furthermore, in light of the weakness of human nature, once the course has been plotted by a DNR ("Do Not Resuscitate") or a "No Code" order, there is a tendency to preclude, eliminate, or reduce other kinds of "ordinary" treatments, such as visits by physicians and care given by nurses and others. Broad orders of "Do Not Resuscitate" (DNR) or "No Code" must be avoided. At no other time in medicine are treatment-orders that are broad and non-specific considered to be within the standard of care.

When it is anticipated that a dying patient could sustain a complication that will be immediately life-threatening and not allow time for reflection and decision, specific orders to direct the Code Blue team response can be written by the primary physician; for example:

  • In the event of cardiac arrest, use or do not use external cardiac massage, defibrillation, etc.

  • In the event of hypotension, use or do not use Dopamine, Levophed, volume expanders, etc.

  • In the event of respiratory arrest, use or do not use bag and mask ventilation, endotracheal intubation, etc.

A companion entry must be made in the medical record, including the diagnosis, prognosis, patient's wishes, recommendations of the treatment team or consultants with documentation of their names and the date. When the patient is unable to communicate for himself/herself, every attempt, including communication with relatives, will be made to obtain informed consent from a proxy.

Ventilation-Respiration

The ventilator, commonly but less properly called a respirator, is a device that is used to move air and/or oxygen in and out of a patient's lungs. Ventilation is the movement of air, while respiration is the exchange of oxygen and carbon dioxide. This exchange occurs in the lungs, as well as in the living tissues throughout the body via the circulation. Ventilation and respiration are essential requirements for life on earth to continue. When these are supported by the use of a ventilator (respirator), such use is more often than not an ordinary means of treatment. When the ventilator is an extraordinary means, the initiation or the continuation of the ventilator is optional. If the use of the ventilator is burdensome in excess of the already existing burdens experienced by the patient, after proper consent and direction, ventilatory support may be slowly decreased (this is known as weaning from the ventilator), which allows the patient to breathe spontaneously if capable of doing so.

Ineffective treatments

Any treatment that is completely ineffective should not be used. Likewise, no treatment that is medically contraindicated could carry any obligation to obtain such treatment. The decision to use or not to use a treatment that is predicted to be wholly or even partially effective must be considered according to the ethical construct of ordinary/extraordinary means.

Persistent vegetative state (PVS)

There are times when a patient has altered brain functions. This is sometimes manifest as a state of unresponsiveness to verbal commands and other higher stimuli. When this lasts for longer than seconds, minutes, hours, or days, it is considered "prolonged" and sometimes called "persistent vegetative state" (PVS). One must be cautious in understanding the meaning of words and how so easily one can refer to a patient in a prolonged state of unresponsiveness as a "vegetable." A human being is never a string bean, a squash, or a pumpkin, thus, never a vegetable. Even when a patient is in a prolonged state of unresponsiveness, including so-called persistent vegetative state, that person is worthy and deserving of care and treatment. Such a patient is not dying or in imminent danger of death, nor does he/she have a lethal disease. The principles of ordinary/extraordinary treatment apply. A means considered ordinary for other patients should not be considered extraordinary with a prolonged state of unresponsiveness because of a judgment that their lives are not worth living.

Dying

When it appears that the patient is dying and that death will occur within hours with or without further treatments, the decision may be made to refuse treatment that would only secure a precarious and burdensome prolongation of life. (Here we use "hours" to avoid the term "imminent," because of overly broad medical/legal interpretation of "imminent" to mean even up to one year.) All ordinary care, however, must not be interrupted. Responsibility for such decisions remains with the patient him/herself, so long as he/she can communicate. When the patient cannot communicate, the physician must obtain a proxy-type consent. This should be as close as possible to the instruction the patient him/herself, if able, would state. Always do what's best to conserve life, fully realizing that life on earth will eventually end for each and everyone. Never withhold or withdraw any treatment with the intention of killing the patient.

Praying

Praying for the patient is encouraged at all times, especially when a patient appears to be dying. When praying with the patient, the kind of prayers should be in accord with those determined by the patient's own religious traditions, method of worship, and clergy. Prayers with a seemingly unconscious patient should be said aloud since the sense of hearing may persist even in apparent unconsciousness. The patient (or in the case of an incompetent patient, the family and/or proxy) should be told that it is common practice to ask if a chaplain, clergy, or the hospital pastoral care service is desired.

Vital organ excision

It is immoral to remove an unpaired vital organ before death. To satisfy a desire for transplantable organs, an ingenious solution was devised to get around this ethical problem: certain comatose patients were simply redefined as "dead." Translating publication of the Harvard Criteria, which defined death as "irreversible coma" and initiated use of so-called brain-related criteria for determining death. It must be realized, however, that only someone alive can be in a coma, even when the coma is "irreversible."

May one excise a beating heart from someone who is warm, has blood pressure, blood circulation readily apparent when pressure is applied to blanch the skin and the color returns within seconds of removal of the pressure, and many other intact, functioning organs and systems maintaining the unity (oneness) of the organism as a whole? Further, if there is doubt that death has occurred, may one excise a vital organ? The answer to both questions should be no. Yet, in accordance with brain-related criteria for death, every time a heart transplant is done, it is a beating heart that is excised. Such organ excision has become so commonplace that fewer and fewer persons question the morality of such action, but there are still some who do.[2]

The human brain and death

The approach of defining death based on brain-related criteria is flawed in both theory and practice. As we will discuss in more detail below, the approach assumes, without adequate scientific or logical basis, that impairment of the function and/or structure of the human brain experienced by certain comatose persons means the absence of "human-ness" and, therefore, life. Moreover, in practice, determination of "brain death" is often made in the absence of some but not all brain functions.

Let us first address the flawed scientific basis for the "brain death" approach.

The cerebral cortex is the largest part of the human brain, and the human cortex is larger than that of other animals. While the attributes of reasoning, thinking and processing information are dependent upon structural integrity of the brain and environmental requirements, it is from structural and/or environmental alterations of the brain and the body of a patient, as well as from animal experiments, that the importance of the cortex for these attributes has been learned. It is the cortex that is primarily responsible for processing these attributes of human beings. Nevertheless, a functioning cortex is not the only part of the brain and body required for these activities.

It is well known that other organs and systems of the body are also required for normal cortical functioning. Could an isolated cortex "possess" rationality? Who knows, but we doubt it. Others would say the entire brain is required, nevertheless stating that rationality resides in the brain. Based upon the interdependence of organs and systems of the human body, it is doubtful that the isolated brain could have rationality. While there can be philosophical speculation or thought experiments (still only a fantasy), the experimental attempts to develop in animals an isolated cortex or isolated brain have met with minimal success or clear failure. Even if one could perfuse the isolated brain and record electrical activity equivalent to or demonstrative of a rational being or even of rationality.

Not only are brain-related criteria flawed in scientific theory but also in application. In order to fulfill the current "brain death" criteria, the entire brain stem must not be functioning. In fact and in practice, however, often only some brain stem reflexes (response of pupil to light, response to ice-water in the ear, gag and swallowing reflexes, etc.) are evaluated. The apnea test (taking the patient off the ventilator) is done to evaluate the function of spontaneous breathing. Although there are other functions of the brain stem, including maintaining a normal body temperature, producing hormones via the hypothalamic-pituitary axis, neurogenic control of heart rate and maintenance of normal blood pressure, either these brain functions are not considered at all or they are said to be not applicable or not significant for determining death. Moreover, even though the "brain death" criteria of the Uniform Determination of Death Act (UDDA) calls for "...irreversible cessation of all functions of the entire brain, including the brain stem," it is and has been acceptable practice that at the time of "brain death" determination, some of the above functions are often present but not evaluated. Furthermore, in the more recently published Guidelines for Determination of Brain Death in Children, the #3 requirement is that the "patient must not be significantly hypothermic or hypotensive for age" when the determination of "brain death" is made.[5] When the body temperature is normal without control by environmental warming or cooling, and when the blood pressure is normal without control by pressor drugs, the brain must be functioning. Even if the temperature and blood pressure are normal as a result of medical treatment, isn't it likely that one is still dealing with someone who is alive rather than dead?

As the foregoing indicates, the observation of the vital signs of a normal temperature and normal blood pressure, as well as the possibility of the presence of non-evaluated and non-tested brain functions, is medically and legally acceptable as compatible with a determination of "brain death." Not only has it been acceptable at all other ages, it is now also required that these vital signs of normal temperature and normal blood pressure be present when making a determination of "brain death" in children. What, then, is it that we are being made to accept under brain-related criteria for death? We are being made to accept an entree for organ transplant teams to obtain vital organs in good physiological condition. As we will discuss in more detail below, from an ethical point of view, one cannot remove an unpaired vital organ from an individual if there is any question that she/he might be alive.

While the automobile is a poor analogy for any comparison to a human being, some thoughts expressed here may help elucidate the difference between functions and functioning. An automobile, currently parked, is not functioning. While its functioning has ceased for the time being, its functions are still present-it takes only a driver and an ignition key to activate the auto. These differences are not merely semantics, but are factual differences that have resulted in so many having been misled in this serious matter of "brain death." When brain-related criteria are applied in making a determination of death, an absence of functioning is observed. It is then erroneously, indeed illogically, concluded that there is an absence of functions.

In sum, there are more than 30 different sets of brain related criteria that are in use. None are based or applied on adequate theory or data. When a determination of "brain death" is made and is then followed by excision of a beating heart, the criteria become self-fulfilling for death.

It is not possible to excise an unpaired vital organ from a corpse and then use the organ for transplant. Specifically, for a heart to be suitable for transplant, it must be taken while beating from someone with intact circulatory and respiratory systems and often a functioning brain stem, as well as many other intact organs and systems that are functioning and maintaining unity of the body. If there is any question that death has not occurred for these vital organ donors, there exists a moral prohibition to excise an unpaired vital organ, which would insure that death is the reality for the one from whom the organ would be taken.

Typically, the patient determined to be "brain dead" under brain-related criteria is on a ventilator in an intensive care unit. The ventilator (less properly called a respirator) moves air. A ventilator can cause air to move in and out of the chest of a corpse, but it can never cause a corpse to respire. Respiration is a vital function carried out only by someone who is alive. In a corpse there cannot be any respiration, that is, exchange of oxygen and carbon dioxide, across the alveolar membrane, although a ventilator could move air in and out of the chest. In this "brain dead" patient, however, respiration is still occurring.

A functioning brain is not necessary for the heart to beat. The beating of the heart is intrinsic to the heart, but heartbeat of such cardiogenic origin is at a slower rate than heartbeat of neurogenic origin which one ordinarily observes in a healthy person, e.g., during routine physical examination. When the heart is beating without a functioning brain stem, the rate is much slower than normal and the blood pressure quickly goes down. When the "brain dead" donor and his or her beating heart are being prepared for transplantation, the heart is still beating-and often not even at this slower rate indicating that the heartbeat is only of cardiogenic origin.

In our view (a view regrettably not shared by the "establishment" medical profession), death cannot and should not be determined unless and until there is destruction of at least the three basic unifying systems of the body-the brain, cardiovascular/circulatory and the respiratory systems. Our insistence on "destruction" is primarily a concern not with the impossibility of a restoration of function of these systems, but with the radical incapacity of these systems to function at the present moment. (For a detailed discussion of this standard, see infra note 2, Gonzaga Law Review.)

This standard avoids the flaws of brain-related criteria for death, as discussed above. We must recognize, however, that its application would foreclose some of the transplant activity currently being conducted. Nonetheless, it is the only religiously and morally acceptable standard for ensuring that living human beings are not too hastily treated as dead.

Caution and courage

While the intention of some authors is good and well meaning, it is essential to be aware of the intricacies of activities and movements of proponents of "brain death" and euthanasia to hurry the comatose, "less than perfect," unresponsive patients off the earth. Such activities and movements are not so subtle as to go undetected, but the lack of understanding by many who would otherwise take a respect-for-life stand results in their taking a position not only of accepting brain-related criteria for death, but also of actively or passively fostering and supporting "brain death."

"Brain death" is not death. If it were identical and equivalent to death, why would it be necessary to coin a new term? Semantics, verbal engineering, emotional and social reasons have resulted in creating a fiction of death-to carry out research and vital organ transplantation. At present, those in a "persistent vegetative state" (PVS) do not satisfy currently accepted criteria for "brain death." But, the euthanasia via "brain death" has been followed by the killing of others who are unresponsive; water and food have been removed causing death via dehydration and starvation-often after a court ruling. These activities will be followed by other forms of killing and, indeed, further redefinitions of death to encompass PVS patients and more are already being proposed. These activities will continue until there are sufficient numbers who have the courage to say, "No! - No, to 'brain death' and mercy killing!"


Principles and guidelines

  • Human life is sacred; God alone is the author of a person's life, and He alone may determine when a person's life will end. Since human life is a gift from God, there is a primary moral obligation to show reverence for that life at all times from its beginning until death. Any failure to show reverence for or to safeguard a patient's life is an attack on the individual patient, on others involved, on the medical profession, on society, and on God.

  • No physician, nurse, or other personnel or caregiver should participate in assisted suicide or euthanasia. By euthanasia is meant an action or omission which of itself or by intention causes death, in order that suffering may in this way be eliminated. No one shall be deprived of basic care, including food and water, suitable bedding, an optimal thermal environment, a patent airway, exits for stool and urine, and available effective treatments and therapies. A physician may not encourage a patient to violate his or her moral obligations (cf. 3), help him or her to do so, or refuse a patient's request for a treatment or therapy that is obligatory.

  • A patient has a moral obligation to use any treatment, medication or operation which offers a reasonable hope of benefit without requiring virtue that is above and beyond ordinary virtue, e.g., without causing excessive pain, expense or other grave burden to the patient himself or herself.

  • The patient has the moral option to consent to or to refuse any treatment, medication or operation that would require heroic virtue or be gravely burdensome to himself or herself.

  • A hospital exists to diagnose and treat ill patients. The object is always to provide the best available medical care to the patient. Consequently, for a hospital to purposefully expedite death by omission or commission violates a fundamental principle of medicine-"First, do no harm." Recognizing that not every illness can be cured, but that every patient must be cared for, a hospital cooperates with other facilities and services, as well as the patient's family, to deliver the best care possible to the patient.

  • When it is determined that a patient is dying of a lethal disease that is medically irremediable and it is predicted that death will occur within hours with or without treatment or therapy, the patient has the moral option to request or refuse such treatment or therapy. (Here we use "hours" to avoid the term "imminent," because of overly broad medical/legal interpretation of "imminent" to mean even up to one year.) The physician must be morally certain that he/she has done all in his/her power in accord with the wishes of the patient to help him or her live the life span given by God.

  • There is an obligation for the physician and the hospital to provide a treatment or therapy that is gravely burdensome to the patient when the patient wishes such treatment.

  • When the patient is unable to communicate and (1) it has been made known that the patient still has obligations to others, which this treatment could help him or her to meet, or (2) it has been made known that the patient's spiritual needs have not been met, the physician should gently encourage use of a gravely burdensome treatment or therapy to the family and/or proxy.

  • Praying for the patient is encouraged at all times, especially when a patient appears to be dying. When praying with the patient, the kind of prayers should be in accord with those determined by the patient's own religious traditions, method of worship, and clergy. Prayers with a seemingly unconscious patient should be said aloud since the sense of hearing may persist even in apparent unconsciousness. The patient (or in the case of the incompetent patient, the family and/or proxy) should be told it is common practice to ask if a chaplain, clergy, or other hospital pastoral care service is desired.

Policies

  • It is generally the right of a patient capable of giving informed consent to make his or her own decisions regarding medical care after having been fully informed about the benefits, risks and consequences of available treatment.

  • There shall be ongoing clarification to the patient (and participating family members) of the risk/benefit of specific treatments. This must be documented in the medical record.

  • Within the parameters of these principles and guidelines, when a patient is not able to give informed consent and when the treatment is morally optional, the physician must obtain consent from a proxy. Ideally, a responsible relative, the parents or guardian of a minor child, the conservator of an adult or the designated proxy makes the decision in the way the patient would make the decision if he or she were able and had all the current information. Thus, a current judgment is made about current matters. To do this, the physician must keep those responsible for decision-making currently informed. If there is insufficient knowledge to make such a decision, one may have to make a judgment based on the patient's "best interests," always keeping foremost that human life is sacred and that the life span on earth must be determined only by God Himself. All, including physicians, must always provide ordinary care and treatments. If the patient or the proxy would direct to withhold or withdraw effective, non-burdensome lifesaving treatment, no one, including physicians, may participate in carrying out such a directive.

  • In the absence of instructions by the patient and/or proxy, life-saving, life-sustaining and life-prolonging measures will be used to preserve the life of the patient.

  • When it is directed by a dying patient or the patient's proxy that a gravely burdensome treatment will not be administered, an order for that specific non-treatment must be written. Broad orders of "Do Not Resuscitate" or "No Code" must be avoided.

    When it is anticipated that a dying patient could sustain a complication that will be immediately life-threatening and not allow time for reflection and decision, specific orders to direct the Code Blue team response can be written by the primary physician; for example:

    • In the event of cardiac arrest, use or do not use external cardiac massage, defibrillation, etc.

    • In the event of hypotension, use or do not use Dopamine, Levophed, volume expanders, etc.

    • In the event of respiratory arrest, use or do not use bag and mask ventilation, endotracheal intubation, ventilator, etc.

      A companion entry must be made in the medical record, including the diganosis, prognosis, patient's wishes, recommendations of the treatment team or consultants with documentation of their names and the date. When the patient is unable to communicate for himself/herself, every attempt, including communication with relatives, will be made to obtain informed consent from a proxy.

Procedures

  1. The physician's orders shall direct the treatment staff, including the Code Blue team.

  2. The physician's orders shall indicate the desired response to specific events which may be anticipated in the clinical course of the dying patient.

  3. The nursing staff's care plan carries the complete orders for the patient, including any orders relevant to a Code Blue; therefore, the nursing staff shall immediately make such orders known to the responding Code Blue team.

  4. When a proxy must be contacted by phone to obtain permission for treatment, guidelines for witnessing consent to a care plan in behalf of the patient unable to consent for himself or herself shall be followed. The physician and a second staff witness (medical or nursing) shall listen to the informed-consent discussion and decision by the proxy. The physician will document this discussion in the medical record, and the second staff member will document his or her participation as a witness.

      Policy for the Determination of Death

      Due to the importance of the determination of death, these principles should be called to mind:

      • The medical determination of whether or not a person has died is a physician's responsibility. This document is intended to assist the physician in making this decision.

      • Human life is sacred; God alone is the Author of a person's life, and He alone may determine when a person's life will end. Because human life is a gift from God, there is a primary moral obligation to show reverence for that life at all times from its beginning until death. Any failure to show reverence for or to safeguard a patient's life is an attack on the individual patient, on others involved, on the medical profession, on society, and on God.

      • Human beings have a primary moral obligation to respect life and to safeguard it. A person who is dying is still alive, even a moment before death, and must be treated as such. Death should be declared only after, not before, the fact. To do the latter is to assent to a falsehood that can lead to actual death prematurely, even through killing. This would be a fundamental injustice.

      • When there is doubt about the fact of death, it is immoral to take an action by which grave harm would be inflicted if the doubt is wrongly resolved, especially since such harm could include premature death. Any doubts must be resolved with the benefit of the doubt always given to the patient's life.

      • From experience it seems clear that once the brain is formed, human life usually, but not always, requires some kind of function of the brain to survive. However, cessation of brain function, functions or functioning, no matter how determined or qualified, is not of itself proof that the person is dead.

      • A person in a coma is still alive and may or may not still demonstrate some evidence of brain function.

      • To regard the irreversibility of cessation of brain functions (at best, a deduction from a set of symptoms) as synonymous or interchangeable with destruction of the entire brain (one but not the only possible cause of these symptoms) would be erroneous in two ways: identifying the symptoms with their cause and assuming a single cause when several are possible.

      • No one shall be declared dead unless and until there is destruction of at least the three basic unifying systems of the body, namely, the brain, the cardiovascular/circulatory and the respiratory systems.

      References

      1. Dunphy, J.E.: Annual Discourse-On Caring for the Patient with Cancer. New England Journal of Medicine 1976; 295: 313-19.

      2. Evers, J.C., and Byrne, P.A.: Brain Death-Still a Controversy. The Pharos Fall 1990, 10-12. Byrne, P.A., O'Reilly, S., and Quay, P.M.: Brain Death-An Opposing Viewpoint. Journal of the American Medical Association 1979; 242: 1985-90. Byrne, P.A.; O'Reilly, S.; Quay, P.M.; and Salsich, P.: Brain Death-The Patient, the Physician, and Society. Gonzaga Law Review 1982/83; 18/3: 429-516. Quay, P.M.: Utilizing the Bodies of the Dead. St. Louis University Law Journal 1984; 28/4: 889-927.

      3. Cass, L.R.: Death With Dignity and the Sanctity of Human Life. Commentary March 1990; 89/3: 33-43.

      4. Byrne, P.A.; Colliton, W.F.; Diamond, E.F.; Duncan, R.F.; Fangman, T.R.; Kramper, R.J.; et al.: The Physician's Responsibility Toward Sacred Human Life. Linacre Quarterly, Nov. 1986, 14-21.

      5. Task Force on Brain Death in Children: Guidelines for the Determination of Brain Death in Children. Annuals of Neurology 1987; 21: 616-617; Archives of Neurology 1987; 44: 587-588; Neurology 1987; 37: 1077-1078; Pediatric Neurology 1987; 3: 242-243; Pediatrics 1987; 80: 298-299.

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