Advance Healthcare Directives

Pastoral Letter

Kentucky's Advance Health Care Directives: A Catholic Perspective

Preface

In order to protect the rights of its citizens, Congress passed the Patient Self-Determination Act in 1991. This law makes it clear that you have the right to make decisions regarding your medical care including the right to accept or refuse treatment and the right to make an advance directive. The law also requires health care facilities/agencies to discuss advance health care directives with you as you enter their system.

It is advisable to make these health care decisions at a time when you are competent to do so. Making such health care decisions can become confusing for an individual. Technology is available that can respond effectively in many life-threatening situations. Sometimes this same technology that is intended to assist in restoring a person to health can become a mechanism that prolongs the very dying process.

Many seriously ill persons are not competent to make decisions about their care. For this reason many states have passed laws that encourage advance health care directives. By means of such a document, you are able to determine now about the kind of treatment you wish to receive should you become incompetent to make those determinations at the time of your illness. Kentucky passed such legislation in 1990 and refined these laws in 1994. The intent of the laws, as stated within, is to allow adults to delegate the right that is properly theirs to a designated surrogate to make health care decisions. The law does not intend to encourage or discourage any particular health care treatment or to legalize euthanasia, suicide or assisted suicide. Because this is a very serious matter, the Catholic Conference of Kentucky has developed this booklet to offer you guidance from the authentic teachings and traditions of the Catholic faith.

Advance Health Care Directives

With the passage in Kentucky of The Living Will Directive and Health Care Surrogate Designation of 1994, you have two options in preparing your Advance Health Care document. Either decision can be accommodated in a single form created by the General Assembly. The Living Will Directive enables you to make your wishes known regarding life-prolonging treatment in advance of the time when you are no longer able to participate actively in decisions concerning your medical care. The Health Care Surrogate Designation provides the same powers as does the Living Will Directive but, in addition, allows you to designate one or more persons to serve as "surrogate," such as a family member or close friend, to make health care decisions for you if you lose the ability to decide for yourself in the future. This is done by designating a "health care surrogate." A person designating a surrogate is known as a "grantor" under the law.

You . . .

have the right to make all of your own health care decisions so long as you retain the capacity to make decisions. The Advance Health Care Directive only becomes effective should you become incapacitated through illness or accident.

have the right to challenge your doctor’s determination that you are unable to make your own medical decisions.

can give special instructions about your medical treatment to your surrogate and can forbid that surrogate to make certain treatment decisions. You must communicate your wishes, values, religious beliefs, and instructions to your surrogate so that the surrogate will be able to act appropriately on your behalf if you become unable to make medical decisions at a later date. Specific instructions about any treatment/procedures which you desire under specified conditions can be written in your surrogate designation.

have the right to sign a directive without designating a surrogate. In this case the attending physician is required to follow the directions for care that you state in your Living Will Directive.

may revoke your Advance Directive document and the appointment of your surrogate at any time while competent.

may NOT designate as your surrogate, at the time of or subsequent to admission, an employee, owner, director or officer of any health care facility or agency where you, as grantor, reside or are treated, unless that person is a member of the same religious order or is a blood relative within the fourth degree to the grantor.

Options To Consider When Preparing An Advance Directive

The basic difference between a Living Will Directive and a Health Care Surrogate Designation rests in the fact that:

the determinations you make in a Living Will Directive will be carried out according to your written statements by the health care provider who cares for you at the time you are unable to make your own decisions. This may or may not be a person you know.

the determinations you make in a Health Care Surrogate Designation will be carried out by the person or persons you specifically select to act on your behalf. The Health Care Surrogate Designation allows for decisions to be made in light of the existing circumstances which you perhaps could not foresee at the time you create your Advance Health Care Directive. Catholics are encouraged to use the surrogate designation approach because it involves personal interaction, first between the grantor and the surrogate(s), and later between the surrogate(s) and the health care providers. The fact is, however, that some people may not have family members or friends who are able or willing to become surrogates for the patient. In those cases, the Living Will Directive may be helpful in providing direction relative to the patient’s wishes regarding care in terminal illness.

Your Surrogate . . .

can begin making decisions for you only when your doctor determines that you are no longer able to make health care decisions for yourself.

may make any and all health care decisions for you within the boundaries of reasonableness, including treatments for physical and mental conditions and decisions regarding life-sustaining procedures . . . UNLESS you limit the power of your surrogate.

subject to certain exceptions in the law, will have power to authorize the withholding or withdrawal of life-prolonging treatment and decisions about the artificial provision of nutrition and hydration (feeding tubes)

is protected from legal liability when acting in good faith.

must make a decision based on your expressed wishes and values or your "best interests"; this will take precedence over other decisions, regardless of family relationships.

may have his or her decision challenged if your family, health care provider or close friend believes the surrogate is acting in bad faith or is not acting in accord with your wishes and religious/moral beliefs.

Your Health Providers . . .

Neither your health professional nor your health care facility or agency is required to honor your surrogate’s decision if it is contrary to their religious beliefs or sincerely held moral convictions. In such event, they may not prevent or impede your transfer to another facility/health professional willing to honor your surrogate’s decision.

Both your health care professional and health care facility or agency are protected from legal liability when acting in good faith.

Considerations from Catholic Teaching

Roman Catholic teaching celebrates life as a gift of a loving God and respects each human life because each is made in the image and likeness of God.¹

It is consistent with church teaching that each person has the right to make his or her own health care decisions.² Further, a person’s family or others may have to assume that responsibility for someone who has become incapable of making these decisions.² Accordingly, it is morally acceptable to designate health care surrogates, as long as they conform to the teachings and traditions of the Catholic faith.

While the health care surrogate law allows us to designate someone to make health care decisions for us, life is a sacred trust over which we have been given stewardship. We have a duty to preserve it, while recognizing that we have no unlimited power over it. Therefore, the Church encourages us to keep the following considerations in mind if we decide to develop a document like a living will or health care surrogate.

1. As Christians, we believe that our physical life is sacred and that our ultimate goal is everlasting life with God. Therefore, we should accept death as a part of the human condition. Death need not be avoided at all costs.

2. Moreover, ". . . suffering is a fact of human life, and has a special significance for the Christian as an opportunity to share in Christ’s redemptive suffering. Nevertheless, there is nothing wrong in trying to relieve someone’s suffering as long as this does not interfere with other moral and religious duties. For example, it is permissible in the case of terminal illness to use pain killers which carry the risk of shortening life, so long as the intent is to relieve pain effectively rather than to cause death."³

3. "Euthanasia in the strict sense is understood to be an action or omission which of itself and by intention causes death, with the purpose of eliminating all suffering. Euthanasia’s terms of reference, therefore, are to be found in the intention of the will and in the methods used."⁴

4. "Everyone has the duty to care for his or her own health and to seek necessary medical care from others, but this does not mean that all possible remedies must be used in all circumstances. One is not obliged to use ‘extraordinary’ means, that is, means which offer no reasonable hope of benefit or which involve excessive hardship."⁵ Decisions regarding treatment or refusal of treatment should be made in accordance with the principle that there should be some reasonable proportion between the benefit of the treatment and the burden (e.g. pain, risk, cost) it imposes on the patient. ⁶

5. No surrogate is authorized to deny comfort care which every patient can rightfully expect, such as appropriate food, water, bed rest, room temperature and hygiene.

6. The patient’s condition, however, may affect the moral obligation of providing artificial nutrition and hydration. Factors that should be weighed in making this judgment include: the patient’s ability to assimilate the artificially provided nutrition and hydration, the imminence of death and the burden of the procedures for the patient.⁷

7. Life-sustaining treatment must be maintained for a pregnant patient if continued treatment may benefit her unborn child.⁸

8. Such principles and guidelines from our Christian heritage should guide Catholics and others as they strive to make responsible health care decisions and designate health care surrogates. These Christian principles and guidelines should also guide Catholic health care facilities and providers in deciding when to accept and when to refuse to honor a surrogate’s decision.

Practical Considerations For Those Choosing to Designate A Surrogate

1. When possible, prior to or upon entering a health care institution, you should request a copy of the facility’s principles and policies related to advance medical directions.

2. Both you and your surrogate are encouraged to seek sound pastoral guidance before making decisions about life-sustaining treatment. Discuss your questions and beliefs with your pastor or other spiritual advisor.

3. Be prepared to present your advance directives when you enter a health care system. If their policies or principles indicate that they refuse to comply with your advance directive, they are responsible to inform you immediately of the refusal and allow you to transfer to another health care system.

4. Discuss your choices and the reasons for these choices and share copies of your Living Will Directive or Health Care Surrogate Directive with your doctor, your surrogate (if one is named), family members, close friends, your pastor, or anyone else who should be aware of your wishes.

5. As stated above, Catholics are encouraged, where possible, to name a surrogate or surrogates because it involves personal interaction, first between the grantor and the surrogate(s), and later between the surrogate(s) and the healthcare providers.

¹See the Encyclical Evangelium Vitae (The Gospel of Life) of Pope John Paul II, March 25, 1995

²See Declaration on Euthanasia, Sacred Congregation for the Doctrine of the Faith, May 5, 1980, n.IV

³Guidelines for Legislation on Life-Sustaining Treatment. National Conference of Catholic Bishops Administrative Committee, November 10, 1984. Also Evangelium Vitae, #65, 2

⁴Evangelium Vitae, #65, 2

⁵Guidelines for Legislation on Life-Sustaining Treatment. National Conference of Catholic Bishops Administrative Committee, November 10, 1984

⁶Evangelium Vitae, #65, 2

^7Ibid.

⁸Guidelines for Legislation on Life-Sustaining Treatment. National Conference of Catholic Bishops Administrative Committee, November 10, 1984

Catholic Conference of Kentucky

1042 Burlington Lane

Frankfort, Kentucky 40601

502-875-4345 502-875-2841 Fax cckstaffATccky.org

Pastoral Letter

Kentucky's Advance Health Care Directives: A Catholic Perspective

Last modified: April, 2008