You are probably reading this page to gain more information about palliative and hospice care, and whether they are compatible with Catholic teaching and doctrine. A good place to start is with definitions:
Palliative care
From the National Consensus Project for Quality Palliative Care: www.nationalcoalitionhpc.org/ncp/
... is medical care that is "Beneficial at any stage of a serious illness, palliative care is an interdisciplinary care delivery system designed to anticipate, prevent, and manage physical, psychological, social, and spiritual suffering to optimize quality of life for patients, their families and caregivers . Palliative care can be delivered in any care setting through the collaboration of many types of care providers . Through early integration into the care plan of seriously ill people, palliative care improves quality of life for both the patient and the family." Palliative can can be received at any time, along WITH curative treatment, and anywhere. It is paid by private insurance or out-of-pocket but the expense, per se, is not covered by Medicare or Medicaid. It is important to know that palliative care can be delivered by any doctor or clinician who is caring for anyone who is very ill, no matter where they are. There are some doctors who just practice palliative care medicine and have additional training in this field. But in fact, EVERY doctor or clinician should practice palliative care, since it is just good "doctoring".
Pope St. John Paul II, said, in his Address To the Participants in the 19th International Conference of the Pontifical Council for Pastoral Health Care, delivered 11/12/2004: www.ewtn.com/catholicism/library/pontifical-council-for-health-pastoral-care-19th-international-conference-8353
2. Medicine is always at the service of life. Even when medical treatment is unable to defeat a serious pathology, all its possibilities are directed to the alleviation of suffering. Working enthusiastically to help the patient in every situation means being aware of the inalienable dignity of every human being, even in the extreme conditions of terminal illness. Christians recognize this devotion as a fundamental dimension of their vocation: indeed, in carrying out this task they know that they are caring for Christ himself. (cf. Mt 25: 35-40).
5. Particularly in the stages of illness when proportionate and effective treatment is no longer possible, while it is necessary to avoid every kind of persistent or aggressive treatment, methods of “palliative care” are required. As the encyclical Evangelium vitae affirms, they must “seek to make suffering more bearable in the final stages of illness and to ensure that the patient is supported and accompanied in his or her ordeal” (n. 65). In fact, palliative care aims, especially in the case of patients with terminal diseases, at alleviating a vast gamut of symptoms of physical, psychological, and mental suffering; hence, it requires the intervention of a team of specialists with medical, psychological, and religious qualifications who will work together to support the patient in critical stages.
So, palliative care is just good medical care, delivered for the relief of symptoms, and is entirely consistent with Catholic teaching and doctrine.
Hospice Care
Hospice is a specific type of palliative care provided to individuals with a life expectancy measured in months, not years. Hospice is also a specific medical benefit that is paid for by Medicare, Medicaid, and many private health insurers. To receive the hospice benefit, adult patients must have a life-expectancy of 6 months or less if the disease follows its usual course (certified by two physicians) and the person desires care for comfort only. The person receiving hospice CANNOT be utilizing curative treatment for the diagnosis/disease which is causing the shortened life-expectancy. with one exception - Since 2010, pediatric patients CAN receive treatments for the terminal condition, while also receiving hospice services. In 2016, almost half of the people who died while receiving Medicare, were getting hospice care. Most of the care you get from hospice is provided in your home, a nursing home, or in skilled nursing facilities. It can be provided in the hospital, too. Basically, wherever you are. The level of care provided relates to the severity of the symptoms, and especially the need for licensed personnel. Typically, in order to qualify for hospice in the hospital, symptoms must be out of control and requiring intravenous or intramuscular injections around the clock, that can only be administered by a licensed medical professional.
Hospice is a specific Medicare benefit program/benefit: https://www.medicare.gov/coverage/hospice-care
Pay attention to what Medicare will NOT pay for if you select to have them pay for hospice. It is down the web page in "Things to know".
1. Treatment intended to cure your terminal illness and/or related conditions. Talk with your doctor if you're thinking about getting treatment to cure your illness. As a hospice patient, you always have the right to stop hospice care at any time.
2. Prescription drugs to cure your illness (rather than for symptom control or pain relief).
3. Care from any hospice provider that wasn't set up by the hospice medical team. You must get hospice care from the hospice provider you chose. All care that you get for your terminal illness must be given by or arranged by the hospice team. You can't get the same type of hospice care from a different hospice, unless you change your hospice provider. However, you can still see your regular doctor or nurse practitioner IF you've chosen him or her to be the attending medical professional who helps supervise your hospice care, and they agree to do so (many will not).
4. Room and board. Medicare doesn't cover room and board if you get hospice care in your home or if you live in a nursing home or a hospice inpatient facility. If the hospice team determines that you need short-term inpatient or respite care services that they arrange, Medicare will cover your stay in the facility. You may have to pay a small copayment for the respite stay.
5. Care you get as a hospital outpatient (like in an emergency room), care you get as a hospital inpatient, or ambulance transportation, unless it's either arranged by your hospice team or is unrelated to your terminal illness and related conditions.
When in doubt, contact your hospice team before you get any of these services or you might have to pay the entire cost.
Palliative care
From the National Consensus Project for Quality Palliative Care: www.nationalcoalitionhpc.org/ncp/
... is medical care that is "Beneficial at any stage of a serious illness, palliative care is an interdisciplinary care delivery system designed to anticipate, prevent, and manage physical, psychological, social, and spiritual suffering to optimize quality of life for patients, their families and caregivers . Palliative care can be delivered in any care setting through the collaboration of many types of care providers . Through early integration into the care plan of seriously ill people, palliative care improves quality of life for both the patient and the family." Palliative can can be received at any time, along WITH curative treatment, and anywhere. It is paid by private insurance or out-of-pocket but the expense, per se, is not covered by Medicare or Medicaid. It is important to know that palliative care can be delivered by any doctor or clinician who is caring for anyone who is very ill, no matter where they are. There are some doctors who just practice palliative care medicine and have additional training in this field. But in fact, EVERY doctor or clinician should practice palliative care, since it is just good "doctoring".
Pope St. John Paul II, said, in his Address To the Participants in the 19th International Conference of the Pontifical Council for Pastoral Health Care, delivered 11/12/2004: www.ewtn.com/catholicism/library/pontifical-council-for-health-pastoral-care-19th-international-conference-8353
2. Medicine is always at the service of life. Even when medical treatment is unable to defeat a serious pathology, all its possibilities are directed to the alleviation of suffering. Working enthusiastically to help the patient in every situation means being aware of the inalienable dignity of every human being, even in the extreme conditions of terminal illness. Christians recognize this devotion as a fundamental dimension of their vocation: indeed, in carrying out this task they know that they are caring for Christ himself. (cf. Mt 25: 35-40).
5. Particularly in the stages of illness when proportionate and effective treatment is no longer possible, while it is necessary to avoid every kind of persistent or aggressive treatment, methods of “palliative care” are required. As the encyclical Evangelium vitae affirms, they must “seek to make suffering more bearable in the final stages of illness and to ensure that the patient is supported and accompanied in his or her ordeal” (n. 65). In fact, palliative care aims, especially in the case of patients with terminal diseases, at alleviating a vast gamut of symptoms of physical, psychological, and mental suffering; hence, it requires the intervention of a team of specialists with medical, psychological, and religious qualifications who will work together to support the patient in critical stages.
So, palliative care is just good medical care, delivered for the relief of symptoms, and is entirely consistent with Catholic teaching and doctrine.
Hospice Care
Hospice is a specific type of palliative care provided to individuals with a life expectancy measured in months, not years. Hospice is also a specific medical benefit that is paid for by Medicare, Medicaid, and many private health insurers. To receive the hospice benefit, adult patients must have a life-expectancy of 6 months or less if the disease follows its usual course (certified by two physicians) and the person desires care for comfort only. The person receiving hospice CANNOT be utilizing curative treatment for the diagnosis/disease which is causing the shortened life-expectancy. with one exception - Since 2010, pediatric patients CAN receive treatments for the terminal condition, while also receiving hospice services. In 2016, almost half of the people who died while receiving Medicare, were getting hospice care. Most of the care you get from hospice is provided in your home, a nursing home, or in skilled nursing facilities. It can be provided in the hospital, too. Basically, wherever you are. The level of care provided relates to the severity of the symptoms, and especially the need for licensed personnel. Typically, in order to qualify for hospice in the hospital, symptoms must be out of control and requiring intravenous or intramuscular injections around the clock, that can only be administered by a licensed medical professional.
Hospice is a specific Medicare benefit program/benefit: https://www.medicare.gov/coverage/hospice-care
Pay attention to what Medicare will NOT pay for if you select to have them pay for hospice. It is down the web page in "Things to know".
1. Treatment intended to cure your terminal illness and/or related conditions. Talk with your doctor if you're thinking about getting treatment to cure your illness. As a hospice patient, you always have the right to stop hospice care at any time.
2. Prescription drugs to cure your illness (rather than for symptom control or pain relief).
3. Care from any hospice provider that wasn't set up by the hospice medical team. You must get hospice care from the hospice provider you chose. All care that you get for your terminal illness must be given by or arranged by the hospice team. You can't get the same type of hospice care from a different hospice, unless you change your hospice provider. However, you can still see your regular doctor or nurse practitioner IF you've chosen him or her to be the attending medical professional who helps supervise your hospice care, and they agree to do so (many will not).
4. Room and board. Medicare doesn't cover room and board if you get hospice care in your home or if you live in a nursing home or a hospice inpatient facility. If the hospice team determines that you need short-term inpatient or respite care services that they arrange, Medicare will cover your stay in the facility. You may have to pay a small copayment for the respite stay.
5. Care you get as a hospital outpatient (like in an emergency room), care you get as a hospital inpatient, or ambulance transportation, unless it's either arranged by your hospice team or is unrelated to your terminal illness and related conditions.
When in doubt, contact your hospice team before you get any of these services or you might have to pay the entire cost.
hhs.texas.gov/sites/default/files/documents/services/health/palliative-care/palliative-vs-hospice-venn-diagram.pdf
What this diagram shows is that both palliative care and hospice care should
Optimize Comfort
Reduce stress
Provide emotional and spiritual support
Relieve symptoms
The differences between the two are practical and primarily center around funding.
Hospice care is therefore also in agreement with Catholic teaching. Each of the last 3 Popes has issued a statement in favor of palliative and hospice care. In providing palliative and hospice care, we are taking care of one another (Matthew 25), especially those who suffer, accompanying each other to the end of life. We have a moral duty to do this. Besides physical symptoms, people often experience great fear and anxiety as they near death. Hospice and palliative care can help to create a loving presence around the dying person so that hope prevails over anguish (New Charter for Health Care Workers: www.ncbcenter.org/free-scribd-texts/new-charter-for-health-care-workers). Hospice, in particular, can be of great help in the finals months of life, but ONLY IF IT IS DONE CORRECTLY.
Here is the problem with hospice. Some agencies do not always practice it correctly. Here are some of the possible practice shortcomings:
1) Withholding antibiotics for infections or other medications to treat chronic conditions
2) Not monitoring or treating pain adequately
3) Over-medicating pain, so that patients are sedated without need
4) Excessive sedation - palliative sedation. Patients should remain conscious to properly prepare for death.
5) Not feeding patients who cannot feed themselves. This includes helping the patient and possibly even use of a feeding tube.
6) Agreeing with physician-assisted suicide in states where it is legal. It is not legal in Texas so no agency is going to agree to it here.
Additional Hospice information resources:
1. Medicaid (in Texas): https://hhs.texas.gov/laws-regulations/handbooks/mepd/chapter-a-general-information-mepd-groups/a-5000-texas-medicaid-hospice-program#:~:text=Persons%20eligible%20for%20full%20Medicaid,months%20or%20less%20to%20live.&text=Hospice%20services%20may%20be%20received,contracted%20long%2Dterm%20care%20facility
2. From Don McCoy: hospice_care_information_sheet_-_don_mccoy_2020-09.pdf
3. From Ron Panzer, RN: a longtime advocate for Pro-Life Hospice. He has just retired (10/2020), but his website has been archived and is available here: web.archive.org/web/20201022050139/https://www.hospicepatients.org/
Click on Main Hospice Topics (left-hand side), then 2. Choosing Hospice: is it right for you?
He has authored a book, entitled "Stealth Euthanasia" in which he details some of the abuses of hospice. It is an online book available here (for now): www.hospicepatients.org/this-thing-called-hospice.html
4. National Catholic Bioethics Center (Palliative care and Hospice):
www.ncbcenter.org/store/catholic-guide-to-palliative-care-and-hospiceenglishpdf-download.
$2.50 for digital download
5. National Catholic Bioethics Center (General End of Life):
www.ncbcenter.org/store/catholic-guide-to-end-of-life-decisions-english-pdf-download
$2.50 for digital download
For the NCBC documents, we have additional copies we can mail to you. Send us an email [email protected])
Selecting a Hospice Agency:
If you have a serious illness, at some point, someone will probably mention "hospice".
As of 12/1/2020, the Medicare website showed 184 agencies offering Hospice care in Dallas, TX:
www.medicare.gov/care-compare/results?searchType=Hospice&page=3&city=Dallas&state=TX&sort=alpha
You can compare some features of the agencies on the website:
1) the conditions of the patients who are being treated (cancer, dementia, stroke, etc.)
2) what % have those conditions
3) the average daily number of patients the hospice agency cares for
4) where they provide the care (home, living facility, hospital or other)
5) whether they provide just routine home care or provide more services
6) results of surveys from family member's or friend's experience compared with a national average (like user reviews on Amazon)
7) whether they are non-profit or for-profit or other
8) when they were certified by Medicare.
There are no hospice agencies servicing Dallas, TX, which are specifically "Catholic" or recognized as such by the local ordinary of the Diocese of Dallas, Bishop Edward Burns, who has jurisdiction in this regard. However, non-Catholic hospices may follow practices which are consistent with Catholic teaching.
We recommend starting with a few agencies recommended by your doctor, the staff at the hospital, or friends who have had a good experience with a particular agency.
We don't endorse any particular hospice or hospices, but these agencies have a good reputation (recommended by doctors and staff at area hospitals). This list is not exhaustive and may omit some agencies which do offer good care. They are listed in alphabetical order:
1. Alevcare Hospice
315 S Main St
Mansfield, TX 76063
(469) 630-2538
2. Community Hospice of Texas
1341 W Mockingbird Lane # 210e
Dallas, TX 75247
(214) 920-8450
Tends to be focused on pediatrics throughout metroplex; adult hospice in Ft. Worth
3. Dignity Hospice
13601 Preston Road, Suite E200
Dallas, TX 75240
(972) 997-5941
4. Faith Presbyterian Hospice
12477 Merit Dr
Dallas, TX 75251
(972) 239-5300
Also offers in-patient hospice at their own free-standing facility
5. Hospice Plus
2777 N. Stemmons Freeway, Suite 1100
Dallas, TX 75207
(903) 675-4444
6. Kindred Hospice
7557 Rambler Road Suite 112
Dallas, TX 75231
(214) 231-3914
7. Pathway Hospice LLC
1021 Hampshire LN
Richardson, TX 75080
(214) 377-9377
8. Three Oaks Hospice, Inc.
717 N Harwood St Suite 550
Dallas, TX 75201
(214) 628-9951
9. Three Oaks Palliative Care
717 N Harwood St Suite 550
Dallas, TX 75201
(877) 585-7400
10. Vitas Healthcare of Texas LP
14651 N. Dallas Parkway Suite 812
Dallas, TX 75254
(214) 424-5600
Also offers in-patient hospice on a hospital floor at BSW Carrollton & Methodist Dallas
11. VNA
1420 W. Mockingbird Lane, Suite 700
Dallas, TX 75247
(214) 689-0000
Interviewing Hospice Agencies
You can and should "interview" the agencies using these questions, taken from the National Catholic Bioethics Center, Medicare (www.medicare.gov/care-compare/en/assets/resources/hospice/HospiceChecklist-Final-Clean.pdf), and the Illinois Right-to-Life organization (illinoisrighttolife.org/end-of-life/25-questions-you-should-ask-your-hospice/).
For these questions, whenever "patient" is used, this also includes the medical power of attorney, in case the patient is unable to make the decision for him/her self.
Questions for which we believe the correct answer is "Yes" or "at the request of the patient"
1. Will this hospice accept a patient who is fed through a feeding tube or IV?
2. Will this hospice continue feeding the patient with a feeding tube or IV?
3. Will this hospice establish a feeding tube or IV if necessary to provide nutrition and hydration to the patient?
4. Will this hospice continue to administer medications that are stabilizing a chronically ill patient, when the patient is not actively dying?
5. Will this hospice treat patient infections with antibiotics?
6. Will this hospice reject any patient request for assisted suicide? Does the agency provide services in the follow states/districts: California, Colorado, Washington, DC, Hawaii, Maine, Montana, New Jersey, Oregon, Vermont, or Washington? If so, will they reject patient requests for assisted suicide there?
7. Will oxygen be provided if it is needed to keep the patient comfortable?
8. Will physical therapy be provided if it will help the patient’s condition to improve (e.g. after a stroke to recover use of limbs)?
9. If a patient/family refuses to accept a medication, will the patient’s decision be respected?
10. Will this hospice treat bedsores if the patient is not at the very end phase of dying?
11a. Will this hospice provide references that can be checked?
11b. Has the hospice license ever been suspended or revoked?
12. Do we have access to hospice staff 24×7 in case there is a problem controlling pain or some other distress condition arises? Who has access? What is typical response time?
13. Does this hospice decline to accept severely disabled patients who are not terminal?
14. Does this hospice decline to accept chronically ill patients who are not terminal?
15. Have I stopped by the hospice unannounced prior to moving a loved one in to see how the patients are treated? (This is only for a hospice facility).
16. Does the hospice offer training for family members for medication administration and equipment usage?
17. Will the hospice agency provide a hospital bed? Other equipment?
For this group of questions, the correct answer is not a simple "Yes" or "No". You are trying to determine the philosophy or practice of the agency:
1. Under what circumstances would a feeding tube or IV be removed?
2. Under what, if any, circumstances would terminal sedation be used? (We prefer the term "palliative" sedation, since terminal sedation could be mis-interpreted as meaning sedating a patient to death.)
3. What levels of pain control will be used and what criteria will determine their use?
4. How frequently will patients needing pain control be monitored for its effectiveness?
5. What type of “comfort care” is this hospice using?
6. How does this hospice define the very end phase of dying and how does that influence any of the other answers to questions?
7. Will this hospice accept a patient who is on dialysis?
8. Will this hospice continue performing dialysis on this patient?
#7 and #8 are difficult. Medicare has recently started to deny coverage for combination hospice and dialysis, and many hospice agencies are afraid to take on patients receiving or about to receive dialysis. Medicare audits are only done after the fact; Medicare could decide that a person should not have received hospice. Then they would demand all of the payments back from the agency for that patient - this threat scares agencies away from taking patients for which Medicare MIGHT take-back the payment.
9. Are there any circumstances where this hospice would demand the discharge of a patient?
10. How does this hospice handle aggressive behavior from an ill or mentally impaired patient?
11. When did the Texas Department of Health and Human Services last conduct a survey and what were the results? - There should not be any unaddressed deficiencies.
12. Have you ever been short-staffed? How do you prevent that from happening?
13. What spiritual care services are offered? Do you have an arrangement for Catholic clergy to administer the sacraments?
14. How does the hospice insure that patients with dementia are nourished properly?
15. How does the hospice handle patients who refuse to eat or drink?
16. How often will I be visited? Who will visit?
17. Under what circumstances can I go to the hospital?
18. Who will my doctor be while I am on hospice?
19. What happens if my caregivers cannot take care of me at home?
Particular Issues Raised by Hospice and Palliative Care:
1. Euthanasia / Assisted-Suicide (also goes by the name Medical Aid in Dying, Physician-Assisted Dying)
Pope St. John Paul II's words are particularly important - taken directly from his address in 2004:
"3. Love of neighbour, which Jesus vividly portrayed in the Parable of the Good Samaritan (cf. Lk 10:2ff.), enables us to recognize the dignity of every person, even when illness has become a burden. Suffering, old age, a comatose state or the imminence of death in no way diminish the intrinsic dignity of the person created in God's image.
Euthanasia is one of those tragedies caused by an ethic that claims to dictate who should live and who should die. Even if it is motivated by sentiments of a misconstrued compassion or of a misunderstood preservation of dignity, euthanasia actually eliminates the person instead of relieving the individual of suffering.
Unless compassion is combined with the desire to tackle suffering and support those who are afflicted, it leads to the cancellation of life in order to eliminate pain, thereby distorting the ethical status of medical science."
"4. True compassion, on the contrary, encourages every reasonable effort for the patient's recovery. At the same time, it helps draw the line when it is clear that no further treatment will serve this purpose.
The refusal of aggressive treatment is neither a rejection of the patient nor of his or her life. Indeed, the object of the decision on whether to begin or to continue a treatment has nothing to do with the value of the patient's life, but rather with whether such medical intervention is beneficial for the patient.
The possible decision either not to start or to halt a treatment will be deemed ethically correct if the treatment is ineffective or obviously disproportionate to the aims of sustaining life or recovering health. Consequently, the decision to forego aggressive treatment is an expression of the respect that is due to the patient at every moment.
It is precisely this sense of loving respect that will help support patients to the very end. Every possible act and attention should be brought into play to lessen their suffering in the last part of their earthly existence and to encourage a life as peaceful as possible, which will dispose them to prepare their souls for the encounter with the heavenly Father."
"Death with Dignity":
It seems to make sense that every person should be able to make their own decision about how and when they die. This sounds like freedom - to live and die according to our own desires and beliefs. In this way people can die peacefully and in a dignified manner of their own choosing. In practice, this doesn't happen and the reality falls far short of this "ideal". From a Catholic perspective this is wrong - our life is not our own to dispose of as we wish. It is a gift from God. Catholic teaching is opposed to physician-assisted or any other form of suicide, even when it is wrapped or presented in a pleasant sounding package like "death with dignity".
Also, consider that most physicians do not support or practice physician-assisted suicide for reasons given in the American College of Physicians position paper:
www.acpjournals.org/doi/10.7326/M17-0938?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
2. Quality of Life
Please be careful about the phrase: "Quality of Life". When we say this we should mean living as well as you can live, considering your illness or disability. By cutting down on physical symptoms, and helping you with emotional or spiritual problems, you can hope to enjoy living, doing the things which bring you joy and happiness and maybe even things you always wanted to do, like spending more time with your family, reading a book you always wanted to read, making-up with someone, or maybe even making-up with God. All lives are worth living; there is NO Quality of Life which is so low that it is not worth living.
The people in favor of mercy-killing or assisted-suicide say that there is a point at which life is not worth living; they are wrong. Do not be deceived by the names these people choose for themselves: "Death With Dignity", "Compassion and Choices", or "Final Options". The names sound good, but all these groups are in favor of euthanasia (mercy-killing) or suicide ("assisted" or otherwise). Also, do not be deceived by the term "assisted suicide" or "Physician-assisted suicide". The only assistance you get is that you are given the means for you to kill yourself. If it is physician-assisted, you get a prescription for pills, which you then fill at the pharmacy, and take yourself, ending your own life. No one is going to administer them to you or push the button or pull the trigger - that is euthanasia and is not legal in the United States.
3. Pain Management
This is probably the area of greatest concern in utilizing hospice and/or palliative care.
Once again, the words of Pope St. John Paul II are important: "The encyclical Evangelium vitae in particular sums up the traditional teaching on the licit use of pain killers that are sometimes called for, with respect for the freedom of patients who should be able, as far as possible, “to satisfy their moral and family duties, and above all ... to prepare in a fully conscious way for their definitive meeting with God” (n. 65). Moreover, while patients in need of pain killers should not be made to forego the relief that they can bring, the dose should be effectively proportionate to the intensity of their pain and its treatment. All forms of euthanasia that would result from the administration of massive doses of a sedative for the purpose of causing death must be avoided."
Neither palliative care not hospice care should seek to shorten life or hasten death. It does sometimes happen, however, that death occurs as a consequence of the treatment offered, If that happens, 4 criteria must be met to meet Catholic moral teaching: 1. The action must be good or neutral as to object, motive and circumstances. 2. The agent must intend the good and not the bad effect. 3. Bad effect cannot be the means for achieving the good effect. The good effect must be caused at least as directly as the bad. In this case, directness refers to causality, not necessarily to temporal relationship. 4. The good effect intended must be proportionate to the bad effect. As an example, it is morally acceptable to administer morphine to relieve air hunger, even if it inadvertently leads to an earlier death for the patient, so long as there is a reasonable expectation that giving the morphine will relieve the air hunger (which is usually the case), and the person administering the medication does not intend to hasten the death of the individual (by giving an excessively high dose).
It is important to know that there is a dose of morphine or other pain medicine which relieves pain and suffering, but which does not render the patient unconscious or lead to their death. If your loved one suddenly becomes unconscious after beginning hospice, you should consider questioning the amount of medication being delivered, especially if they were not experiencing a lot of pain previously.
On the flip side, untreated or inadequately pain and nausea are pressures to select physician-assisted suicide. If this is the case, get better help, don't kill yourself or your loved one. Even though this is often cited as the reason for having the option of assisted-suicide, inadequately treated symptoms are not the main reason people actually choose to seek physician-assisted suicide. These are:
1) Loss of autonomy (control of one's own destiny)
2) Decreased ability to participate in enjoyable activities
3) Loss of Dignity
4. Being a Burden
Many people say "I don't want to be a burden". But what they probably mean is "I don't want to be a bigger burden than I have to be". Also, think about what not "being a burden" means, to those you would be burdening: You are denying them the chance to help you. This might help them to grow emotionally and spiritually. Also, please consider that they may not even feel burdened by the care or help they provide. They may appreciate the opportunity to give back. You may be denying them a blessing from God when you refuse their help.
What if a person feels like they are becoming a burden? What if they are actually told they are becoming a burden? What if a person is made to feel they are selfish for trying to hang on? These are very real possibilities and exert very real pressures on a person to opt for assisted-suicide.
It is sometimes awkward or uncomfortable to be with someone who is watching you suffer. The natural tendency is to want to send them away so you can suffer out of their view. Don't do it. Please consider that you are in a unique position to help them, by allowing them to help you.
5. Patient Autonomy
Though theoretically everyone makes their own decision(s), there can be subtle and sometimes not so subtle pressures upon people to get them to ask for physician-assisted suicide:
Barbara Wagner experienced a not so subtle pressure from the Oregon Health Plan in 2008. She was denied payment for curative treatment for her cancer, but told that the state would pay for her assisted-suicide!
www.youtube.com/watch?v=erzYKNrsx_I&feature=emb_title https://abcnews.go.com/Health/story?id=5517492&page=1
Please also consider that patient autonomy is not absolute (even though some ethicists wrongly consider it the highest good). Every day, physicians
1) advise against tests requested by a patient, when they are not medically appropriate
2) decline to write illegal prescriptions
3) decline to perform unnecessary and sometimes harmful procedures
4) breach confidentiality to protect public health (reporting contagious diseases)
5) decline to engage in futile care
6. Medical Power of Attorney. Advance Directives and Living Wills.
We strongly encourage everyone to have a medical power of attorney. This is the person who speaks in your place about medical decisions, if you are not able. For example, if you are in a coma after an automobile accident this is the person who gives the doctor permission to do procedures (or witholding permission). You should also have a back-up person, just in case your primary person is in the same accident or otherwise not available. So long as you have the medical power of attorney, the Advance Directive is, in our opinion, less important. The person with the medical power of attorney should speak for you, letting the medical team know your wishes, and giving or denying permission for treatments just like you would. Because this person speaks for you (when you can't), make sure this person knows what you want and is willing to say what you would say.
If you live in Texas, you are fortunate because the Bishop of Dallas at that time, Kevin Farrell (now Cardinal Farrell), years ago, asked the St. Thomas More Society (the Catholic lawyers society of Dallas, Texas) to prepare Advance Directive and Medical Power of Attorney forms for people to use, These forms are 1) in agreement with Catholic teaching, 2) legal in the State of Texas, and 3) FREE. They can be found here:
Medical Power of Attorney: www.stmsdallas.org/resources/Documents/End-of-Life%20Working%20Group/Form-STMS%20Medical%20POA%202015.pdf
Advance Directive, also known as a Living Will: www.stmsdallas.org/resources/Documents/End-of-Life%20Working%20Group/Form-STMS%20Advance%20Directive%20July%202015.pdf
7. Fragmentation of Care
You have probably noticed that the more doctors and other providers you have, the more confusing it gets. Each doctor seems to focus on his own area and doesn't want to comment on what the other doctors are doing. Sometimes, the more doctors you have, the less willing they are to talk or to act. This is called the "Bystander Effect" - everyone thinks that someone else will take care of the problem. This happens In medicine, too. (bystander_effect_in_medical_care_nejm_2013.pdf). Hopefully, you will have a team leader who will coordinate things. But if you don't, and you find yourself not getting the sort of information and attention you need, you will need to be more assertive and speak your mind. You will need to ask questions of your doctors and others in your care team about what is wrong and what they will be doing. If you are not able to do this, you can ask a loved one or trusted person to do it for you. If possible, try to keep notes such as the doctor's name, date and time of visit, and what you think they said. You don't necessarily have to record the conversation with a tape-recorder or your phone. Your own impression of what the doctor said is, after-all, what is most important to you.
What this diagram shows is that both palliative care and hospice care should
Optimize Comfort
Reduce stress
Provide emotional and spiritual support
Relieve symptoms
The differences between the two are practical and primarily center around funding.
Hospice care is therefore also in agreement with Catholic teaching. Each of the last 3 Popes has issued a statement in favor of palliative and hospice care. In providing palliative and hospice care, we are taking care of one another (Matthew 25), especially those who suffer, accompanying each other to the end of life. We have a moral duty to do this. Besides physical symptoms, people often experience great fear and anxiety as they near death. Hospice and palliative care can help to create a loving presence around the dying person so that hope prevails over anguish (New Charter for Health Care Workers: www.ncbcenter.org/free-scribd-texts/new-charter-for-health-care-workers). Hospice, in particular, can be of great help in the finals months of life, but ONLY IF IT IS DONE CORRECTLY.
Here is the problem with hospice. Some agencies do not always practice it correctly. Here are some of the possible practice shortcomings:
1) Withholding antibiotics for infections or other medications to treat chronic conditions
2) Not monitoring or treating pain adequately
3) Over-medicating pain, so that patients are sedated without need
4) Excessive sedation - palliative sedation. Patients should remain conscious to properly prepare for death.
5) Not feeding patients who cannot feed themselves. This includes helping the patient and possibly even use of a feeding tube.
6) Agreeing with physician-assisted suicide in states where it is legal. It is not legal in Texas so no agency is going to agree to it here.
Additional Hospice information resources:
1. Medicaid (in Texas): https://hhs.texas.gov/laws-regulations/handbooks/mepd/chapter-a-general-information-mepd-groups/a-5000-texas-medicaid-hospice-program#:~:text=Persons%20eligible%20for%20full%20Medicaid,months%20or%20less%20to%20live.&text=Hospice%20services%20may%20be%20received,contracted%20long%2Dterm%20care%20facility
2. From Don McCoy: hospice_care_information_sheet_-_don_mccoy_2020-09.pdf
3. From Ron Panzer, RN: a longtime advocate for Pro-Life Hospice. He has just retired (10/2020), but his website has been archived and is available here: web.archive.org/web/20201022050139/https://www.hospicepatients.org/
Click on Main Hospice Topics (left-hand side), then 2. Choosing Hospice: is it right for you?
He has authored a book, entitled "Stealth Euthanasia" in which he details some of the abuses of hospice. It is an online book available here (for now): www.hospicepatients.org/this-thing-called-hospice.html
4. National Catholic Bioethics Center (Palliative care and Hospice):
www.ncbcenter.org/store/catholic-guide-to-palliative-care-and-hospiceenglishpdf-download.
$2.50 for digital download
5. National Catholic Bioethics Center (General End of Life):
www.ncbcenter.org/store/catholic-guide-to-end-of-life-decisions-english-pdf-download
$2.50 for digital download
For the NCBC documents, we have additional copies we can mail to you. Send us an email [email protected])
Selecting a Hospice Agency:
If you have a serious illness, at some point, someone will probably mention "hospice".
As of 12/1/2020, the Medicare website showed 184 agencies offering Hospice care in Dallas, TX:
www.medicare.gov/care-compare/results?searchType=Hospice&page=3&city=Dallas&state=TX&sort=alpha
You can compare some features of the agencies on the website:
1) the conditions of the patients who are being treated (cancer, dementia, stroke, etc.)
2) what % have those conditions
3) the average daily number of patients the hospice agency cares for
4) where they provide the care (home, living facility, hospital or other)
5) whether they provide just routine home care or provide more services
6) results of surveys from family member's or friend's experience compared with a national average (like user reviews on Amazon)
7) whether they are non-profit or for-profit or other
8) when they were certified by Medicare.
There are no hospice agencies servicing Dallas, TX, which are specifically "Catholic" or recognized as such by the local ordinary of the Diocese of Dallas, Bishop Edward Burns, who has jurisdiction in this regard. However, non-Catholic hospices may follow practices which are consistent with Catholic teaching.
We recommend starting with a few agencies recommended by your doctor, the staff at the hospital, or friends who have had a good experience with a particular agency.
We don't endorse any particular hospice or hospices, but these agencies have a good reputation (recommended by doctors and staff at area hospitals). This list is not exhaustive and may omit some agencies which do offer good care. They are listed in alphabetical order:
1. Alevcare Hospice
315 S Main St
Mansfield, TX 76063
(469) 630-2538
2. Community Hospice of Texas
1341 W Mockingbird Lane # 210e
Dallas, TX 75247
(214) 920-8450
Tends to be focused on pediatrics throughout metroplex; adult hospice in Ft. Worth
3. Dignity Hospice
13601 Preston Road, Suite E200
Dallas, TX 75240
(972) 997-5941
4. Faith Presbyterian Hospice
12477 Merit Dr
Dallas, TX 75251
(972) 239-5300
Also offers in-patient hospice at their own free-standing facility
5. Hospice Plus
2777 N. Stemmons Freeway, Suite 1100
Dallas, TX 75207
(903) 675-4444
6. Kindred Hospice
7557 Rambler Road Suite 112
Dallas, TX 75231
(214) 231-3914
7. Pathway Hospice LLC
1021 Hampshire LN
Richardson, TX 75080
(214) 377-9377
8. Three Oaks Hospice, Inc.
717 N Harwood St Suite 550
Dallas, TX 75201
(214) 628-9951
9. Three Oaks Palliative Care
717 N Harwood St Suite 550
Dallas, TX 75201
(877) 585-7400
10. Vitas Healthcare of Texas LP
14651 N. Dallas Parkway Suite 812
Dallas, TX 75254
(214) 424-5600
Also offers in-patient hospice on a hospital floor at BSW Carrollton & Methodist Dallas
11. VNA
1420 W. Mockingbird Lane, Suite 700
Dallas, TX 75247
(214) 689-0000
Interviewing Hospice Agencies
You can and should "interview" the agencies using these questions, taken from the National Catholic Bioethics Center, Medicare (www.medicare.gov/care-compare/en/assets/resources/hospice/HospiceChecklist-Final-Clean.pdf), and the Illinois Right-to-Life organization (illinoisrighttolife.org/end-of-life/25-questions-you-should-ask-your-hospice/).
For these questions, whenever "patient" is used, this also includes the medical power of attorney, in case the patient is unable to make the decision for him/her self.
Questions for which we believe the correct answer is "Yes" or "at the request of the patient"
1. Will this hospice accept a patient who is fed through a feeding tube or IV?
2. Will this hospice continue feeding the patient with a feeding tube or IV?
3. Will this hospice establish a feeding tube or IV if necessary to provide nutrition and hydration to the patient?
4. Will this hospice continue to administer medications that are stabilizing a chronically ill patient, when the patient is not actively dying?
5. Will this hospice treat patient infections with antibiotics?
6. Will this hospice reject any patient request for assisted suicide? Does the agency provide services in the follow states/districts: California, Colorado, Washington, DC, Hawaii, Maine, Montana, New Jersey, Oregon, Vermont, or Washington? If so, will they reject patient requests for assisted suicide there?
7. Will oxygen be provided if it is needed to keep the patient comfortable?
8. Will physical therapy be provided if it will help the patient’s condition to improve (e.g. after a stroke to recover use of limbs)?
9. If a patient/family refuses to accept a medication, will the patient’s decision be respected?
10. Will this hospice treat bedsores if the patient is not at the very end phase of dying?
11a. Will this hospice provide references that can be checked?
11b. Has the hospice license ever been suspended or revoked?
12. Do we have access to hospice staff 24×7 in case there is a problem controlling pain or some other distress condition arises? Who has access? What is typical response time?
13. Does this hospice decline to accept severely disabled patients who are not terminal?
14. Does this hospice decline to accept chronically ill patients who are not terminal?
15. Have I stopped by the hospice unannounced prior to moving a loved one in to see how the patients are treated? (This is only for a hospice facility).
16. Does the hospice offer training for family members for medication administration and equipment usage?
17. Will the hospice agency provide a hospital bed? Other equipment?
For this group of questions, the correct answer is not a simple "Yes" or "No". You are trying to determine the philosophy or practice of the agency:
1. Under what circumstances would a feeding tube or IV be removed?
2. Under what, if any, circumstances would terminal sedation be used? (We prefer the term "palliative" sedation, since terminal sedation could be mis-interpreted as meaning sedating a patient to death.)
3. What levels of pain control will be used and what criteria will determine their use?
4. How frequently will patients needing pain control be monitored for its effectiveness?
5. What type of “comfort care” is this hospice using?
6. How does this hospice define the very end phase of dying and how does that influence any of the other answers to questions?
7. Will this hospice accept a patient who is on dialysis?
8. Will this hospice continue performing dialysis on this patient?
#7 and #8 are difficult. Medicare has recently started to deny coverage for combination hospice and dialysis, and many hospice agencies are afraid to take on patients receiving or about to receive dialysis. Medicare audits are only done after the fact; Medicare could decide that a person should not have received hospice. Then they would demand all of the payments back from the agency for that patient - this threat scares agencies away from taking patients for which Medicare MIGHT take-back the payment.
9. Are there any circumstances where this hospice would demand the discharge of a patient?
10. How does this hospice handle aggressive behavior from an ill or mentally impaired patient?
11. When did the Texas Department of Health and Human Services last conduct a survey and what were the results? - There should not be any unaddressed deficiencies.
12. Have you ever been short-staffed? How do you prevent that from happening?
13. What spiritual care services are offered? Do you have an arrangement for Catholic clergy to administer the sacraments?
14. How does the hospice insure that patients with dementia are nourished properly?
15. How does the hospice handle patients who refuse to eat or drink?
16. How often will I be visited? Who will visit?
17. Under what circumstances can I go to the hospital?
18. Who will my doctor be while I am on hospice?
19. What happens if my caregivers cannot take care of me at home?
Particular Issues Raised by Hospice and Palliative Care:
1. Euthanasia / Assisted-Suicide (also goes by the name Medical Aid in Dying, Physician-Assisted Dying)
Pope St. John Paul II's words are particularly important - taken directly from his address in 2004:
"3. Love of neighbour, which Jesus vividly portrayed in the Parable of the Good Samaritan (cf. Lk 10:2ff.), enables us to recognize the dignity of every person, even when illness has become a burden. Suffering, old age, a comatose state or the imminence of death in no way diminish the intrinsic dignity of the person created in God's image.
Euthanasia is one of those tragedies caused by an ethic that claims to dictate who should live and who should die. Even if it is motivated by sentiments of a misconstrued compassion or of a misunderstood preservation of dignity, euthanasia actually eliminates the person instead of relieving the individual of suffering.
Unless compassion is combined with the desire to tackle suffering and support those who are afflicted, it leads to the cancellation of life in order to eliminate pain, thereby distorting the ethical status of medical science."
"4. True compassion, on the contrary, encourages every reasonable effort for the patient's recovery. At the same time, it helps draw the line when it is clear that no further treatment will serve this purpose.
The refusal of aggressive treatment is neither a rejection of the patient nor of his or her life. Indeed, the object of the decision on whether to begin or to continue a treatment has nothing to do with the value of the patient's life, but rather with whether such medical intervention is beneficial for the patient.
The possible decision either not to start or to halt a treatment will be deemed ethically correct if the treatment is ineffective or obviously disproportionate to the aims of sustaining life or recovering health. Consequently, the decision to forego aggressive treatment is an expression of the respect that is due to the patient at every moment.
It is precisely this sense of loving respect that will help support patients to the very end. Every possible act and attention should be brought into play to lessen their suffering in the last part of their earthly existence and to encourage a life as peaceful as possible, which will dispose them to prepare their souls for the encounter with the heavenly Father."
"Death with Dignity":
It seems to make sense that every person should be able to make their own decision about how and when they die. This sounds like freedom - to live and die according to our own desires and beliefs. In this way people can die peacefully and in a dignified manner of their own choosing. In practice, this doesn't happen and the reality falls far short of this "ideal". From a Catholic perspective this is wrong - our life is not our own to dispose of as we wish. It is a gift from God. Catholic teaching is opposed to physician-assisted or any other form of suicide, even when it is wrapped or presented in a pleasant sounding package like "death with dignity".
Also, consider that most physicians do not support or practice physician-assisted suicide for reasons given in the American College of Physicians position paper:
www.acpjournals.org/doi/10.7326/M17-0938?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
2. Quality of Life
Please be careful about the phrase: "Quality of Life". When we say this we should mean living as well as you can live, considering your illness or disability. By cutting down on physical symptoms, and helping you with emotional or spiritual problems, you can hope to enjoy living, doing the things which bring you joy and happiness and maybe even things you always wanted to do, like spending more time with your family, reading a book you always wanted to read, making-up with someone, or maybe even making-up with God. All lives are worth living; there is NO Quality of Life which is so low that it is not worth living.
The people in favor of mercy-killing or assisted-suicide say that there is a point at which life is not worth living; they are wrong. Do not be deceived by the names these people choose for themselves: "Death With Dignity", "Compassion and Choices", or "Final Options". The names sound good, but all these groups are in favor of euthanasia (mercy-killing) or suicide ("assisted" or otherwise). Also, do not be deceived by the term "assisted suicide" or "Physician-assisted suicide". The only assistance you get is that you are given the means for you to kill yourself. If it is physician-assisted, you get a prescription for pills, which you then fill at the pharmacy, and take yourself, ending your own life. No one is going to administer them to you or push the button or pull the trigger - that is euthanasia and is not legal in the United States.
3. Pain Management
This is probably the area of greatest concern in utilizing hospice and/or palliative care.
Once again, the words of Pope St. John Paul II are important: "The encyclical Evangelium vitae in particular sums up the traditional teaching on the licit use of pain killers that are sometimes called for, with respect for the freedom of patients who should be able, as far as possible, “to satisfy their moral and family duties, and above all ... to prepare in a fully conscious way for their definitive meeting with God” (n. 65). Moreover, while patients in need of pain killers should not be made to forego the relief that they can bring, the dose should be effectively proportionate to the intensity of their pain and its treatment. All forms of euthanasia that would result from the administration of massive doses of a sedative for the purpose of causing death must be avoided."
Neither palliative care not hospice care should seek to shorten life or hasten death. It does sometimes happen, however, that death occurs as a consequence of the treatment offered, If that happens, 4 criteria must be met to meet Catholic moral teaching: 1. The action must be good or neutral as to object, motive and circumstances. 2. The agent must intend the good and not the bad effect. 3. Bad effect cannot be the means for achieving the good effect. The good effect must be caused at least as directly as the bad. In this case, directness refers to causality, not necessarily to temporal relationship. 4. The good effect intended must be proportionate to the bad effect. As an example, it is morally acceptable to administer morphine to relieve air hunger, even if it inadvertently leads to an earlier death for the patient, so long as there is a reasonable expectation that giving the morphine will relieve the air hunger (which is usually the case), and the person administering the medication does not intend to hasten the death of the individual (by giving an excessively high dose).
It is important to know that there is a dose of morphine or other pain medicine which relieves pain and suffering, but which does not render the patient unconscious or lead to their death. If your loved one suddenly becomes unconscious after beginning hospice, you should consider questioning the amount of medication being delivered, especially if they were not experiencing a lot of pain previously.
On the flip side, untreated or inadequately pain and nausea are pressures to select physician-assisted suicide. If this is the case, get better help, don't kill yourself or your loved one. Even though this is often cited as the reason for having the option of assisted-suicide, inadequately treated symptoms are not the main reason people actually choose to seek physician-assisted suicide. These are:
1) Loss of autonomy (control of one's own destiny)
2) Decreased ability to participate in enjoyable activities
3) Loss of Dignity
4. Being a Burden
Many people say "I don't want to be a burden". But what they probably mean is "I don't want to be a bigger burden than I have to be". Also, think about what not "being a burden" means, to those you would be burdening: You are denying them the chance to help you. This might help them to grow emotionally and spiritually. Also, please consider that they may not even feel burdened by the care or help they provide. They may appreciate the opportunity to give back. You may be denying them a blessing from God when you refuse their help.
What if a person feels like they are becoming a burden? What if they are actually told they are becoming a burden? What if a person is made to feel they are selfish for trying to hang on? These are very real possibilities and exert very real pressures on a person to opt for assisted-suicide.
It is sometimes awkward or uncomfortable to be with someone who is watching you suffer. The natural tendency is to want to send them away so you can suffer out of their view. Don't do it. Please consider that you are in a unique position to help them, by allowing them to help you.
5. Patient Autonomy
Though theoretically everyone makes their own decision(s), there can be subtle and sometimes not so subtle pressures upon people to get them to ask for physician-assisted suicide:
Barbara Wagner experienced a not so subtle pressure from the Oregon Health Plan in 2008. She was denied payment for curative treatment for her cancer, but told that the state would pay for her assisted-suicide!
www.youtube.com/watch?v=erzYKNrsx_I&feature=emb_title https://abcnews.go.com/Health/story?id=5517492&page=1
Please also consider that patient autonomy is not absolute (even though some ethicists wrongly consider it the highest good). Every day, physicians
1) advise against tests requested by a patient, when they are not medically appropriate
2) decline to write illegal prescriptions
3) decline to perform unnecessary and sometimes harmful procedures
4) breach confidentiality to protect public health (reporting contagious diseases)
5) decline to engage in futile care
6. Medical Power of Attorney. Advance Directives and Living Wills.
We strongly encourage everyone to have a medical power of attorney. This is the person who speaks in your place about medical decisions, if you are not able. For example, if you are in a coma after an automobile accident this is the person who gives the doctor permission to do procedures (or witholding permission). You should also have a back-up person, just in case your primary person is in the same accident or otherwise not available. So long as you have the medical power of attorney, the Advance Directive is, in our opinion, less important. The person with the medical power of attorney should speak for you, letting the medical team know your wishes, and giving or denying permission for treatments just like you would. Because this person speaks for you (when you can't), make sure this person knows what you want and is willing to say what you would say.
If you live in Texas, you are fortunate because the Bishop of Dallas at that time, Kevin Farrell (now Cardinal Farrell), years ago, asked the St. Thomas More Society (the Catholic lawyers society of Dallas, Texas) to prepare Advance Directive and Medical Power of Attorney forms for people to use, These forms are 1) in agreement with Catholic teaching, 2) legal in the State of Texas, and 3) FREE. They can be found here:
Medical Power of Attorney: www.stmsdallas.org/resources/Documents/End-of-Life%20Working%20Group/Form-STMS%20Medical%20POA%202015.pdf
Advance Directive, also known as a Living Will: www.stmsdallas.org/resources/Documents/End-of-Life%20Working%20Group/Form-STMS%20Advance%20Directive%20July%202015.pdf
7. Fragmentation of Care
You have probably noticed that the more doctors and other providers you have, the more confusing it gets. Each doctor seems to focus on his own area and doesn't want to comment on what the other doctors are doing. Sometimes, the more doctors you have, the less willing they are to talk or to act. This is called the "Bystander Effect" - everyone thinks that someone else will take care of the problem. This happens In medicine, too. (bystander_effect_in_medical_care_nejm_2013.pdf). Hopefully, you will have a team leader who will coordinate things. But if you don't, and you find yourself not getting the sort of information and attention you need, you will need to be more assertive and speak your mind. You will need to ask questions of your doctors and others in your care team about what is wrong and what they will be doing. If you are not able to do this, you can ask a loved one or trusted person to do it for you. If possible, try to keep notes such as the doctor's name, date and time of visit, and what you think they said. You don't necessarily have to record the conversation with a tape-recorder or your phone. Your own impression of what the doctor said is, after-all, what is most important to you.