Medical Decisions at the End of Life

Elizabeth Wickham
Reproduced with Permission

What is palliative care?

Traditional palliative care is symptom management when death is imminent - when the patient is actively dying, and death is expected within 24-48 hours. Symptoms such as nausea, shortness of breath, and pain can usually be mitigated or "palliated." Unfortunately, some palliative care groups are now training physicians to introduce palliative care (comfort rather than cure) when death is expected in weeks, months, or even at the first diagnosis of a chronic condition or terminal illness. This trend blurs the distinction between ordinary pain control and end-of-life care (palliative care). Moreover, terminal sedation and withholding hydration (see below) are often part of the mix.

When should food and water be withheld?

Death by starvation and dehydration is painful and inhumane. Withholding food and hydration is imposed death, unless the food/water cannot be assimilated. Nancy Valko, RN, notes: "When people are truly [actively] dying and the body's organs begin to shut down, we often see people lose their appetite and desire to drink much. This is a process that can protect a person from suffering from fluid overload at the end and the dying person remains comfortable. But this is very different from a deliberate decision to 'fast' to death."

What is terminal sedation?

Not to be confused with control of physical pain, the goal of terminal sedation (TS, also known as "palliative sedation" or "total sedation") is "to induce a state of decreased or absent awareness (unconsciousness) in order to relieve the burden of intractable suffering." TS is controversial, and has been called a legal alternative to assisted suicide. Too often TS is used when a patient is not actively dying, and is combined with removal of food and fluids. Withholding food and water can only lead to death. To offer total irreversible sedation to a patient might convey the idea that he or she is a burden, or that his or her life is probably not worth living.

Should I sign a living will?

No. A living will grants consent to decisions in the future, without full knowledge of the medical conditions. Decisions must be made based on current information. A health care power of attorney, designating a proxy, is the preferred advance directive.

Should I be an organ donor?

Pope John Paul II's 2001 address to the International Congress of the Transplantation Society insists there be moral certainty that death has occurred before the transplantation of any unpaired vital organ. Unfortunately, in medicine today determination of death (brain death and non-heart beating death) set standard which are much less stringent than the Holy Father's guidelines. Examples of organs/tissues safe to donate after true death are corneas, heart valves (but not the entire heart), bones, skin, ligaments, and tendons.

How, and why, have medical ethics changed?

Several factors have contributed to changes over the years:

  1. Bioethics: Hospitals and medical schools have appointed bioethicists as ethics experts. Bioethics, as currently practiced, focuses on quality of life. Bioethics expert Dianne Irving, Ph.D., explains that whereas "traditional medical ethics focuses on the physician's duty to the individual patient, whose life and welfare are always sacrosanct," the "focus of bioethics is fundamentally utilitarian, centered, like other utilitarian disciplines, around maximizing total human happiness." Too often, bioethics shifts the emphasis from improving quality of life, to assessing quality of life - weighing the benefits and burdens of life itself.
  2. An entrenched right-to-die belief system: The imposed deaths of Terri Schiavo in 2005, and Nancy Cruzan in 1990, were facilitated by Choice in Dying - a right to die group later called Partnership for Caring. In the '70s and '80s the group was the Society for the Right to Die, and Concern for Dying. Until 1974, it was known as the Euthanasia Society of America. Through name changes and disputes, one focus was constant. From Supreme Court cases, to state living will laws, to physician education, the mission was to popularize the concept of forgoing life-sustaining measures. Partnership disbanded, but many of its members are now in policy-setting positions in hospice and palliative care organizations at the national level. Visit for more information.

Statement from the Congregation for the Doctrine of the Faith

First question: Is the administration of food and water (whether by natural or artificial means) to a patient in a "vegetative state" morally obligatory except when they cannot be assimilated by the patient's body or cannot be administered to the patient without causing significant physical discomfort?

Response: Yes. The administration of food and water even by artificial means is, in principle, an ordinary and proportionate means of preserving life. It is therefore obligatory to the extent to which, and for as long as, it is shown to accomplish its proper finality, which is the hydration and nourishment of the patient. In this way suffering and death by starvation and dehydration are prevented.

Second question: When nutrition and hydration are being supplied by artificial means to a patient in a "permanent vegetative state," may they be discontinued when competent physicians judge with moral certainty that the patient will never recover consciousness?

Response: No. A patient in a "permanent vegetative state" is a person with fundamental human dignity and must, therefore, receive ordinary and proportionate care which includes, in principle, the administration of water and food even by artificial means.

The Supreme Pontiff Benedict XVI, at the Audience granted to the undersigned Cardinal Prefect of the Congregation for the Doctrine of the Faith, approved these Responses, adopted in the Ordinary Session of the Congregation, and ordered their publication.

Rome, from the Offices of the Congregation for the Doctrine of the Faith
August 1, 2007.
William Cardinal Levada

Angelo Amato, S.D.B.
Titular Archbishop of Sila

Helpful Contacts

American Life League *
P.O. Box
Stafford, VA 22555;
Phone: 540-659-4171
LifeTree highly recommends: "Life, Life Support, and Death" (second edition: 2005)

Hospice Patients Alliance **
4680 Shank Street
Rockford, MI 49341
Phone: 616-866-9127

Human Life Alliance **
3570 Lexington Avenue North, Suite 205
Saint Paul, MN 55126
Phone: 651-484-1040

National Association of Pro-Life Nurses **
P.O. Box 8236
Hot Springs Village, AR 71910-8236
Phone: 501-992-5905

* Catholic organization
** Non-denominational