John F. Morris, Ph.D.

As everyone reading this knows, the COVID-19 pandemic has affected many different aspects of health care. One area that has been especially impacted is end-of-life care due to the risk of exposure and possible transmission of the virus during patient interactions. One sad outcome of this that we have all become familiar with is the strict visitation limits put in place by hospitals across the country for COVID positive patients, which in many cases meant family members were unable to be present with a loved-one throughout their illness — even when the patient was dying. These visitation limits also made the provision of end-of-life sacraments a challenge for Catholics who desired them due to the close interaction of priests ministering these to infected patients.

Reminder of the Fundamentals for the Sacrament of the Anointing of the Sick
Catholic medical facilities adapted quickly, following previously established protocols for the provision of end-of-life sacraments under emergency circumstances as during a pandemic. For example, in March of 2020 the Catholic Health Association posted a document, "Reminder of the Fundamentals for the Sacrament of the Anointing of the Sick," which explained that while Canon Law indicates anointings are to be done by the priest with his hand, exceptions are allowed for a grave reason such as when there is risk of infection, and they are able to use an instrument such as a cotton ball or swab instead which can be safely discarded afterwards. Indeed, referencing the New Commentary on the Code of Canon Law, the CHA "Reminder" specifically noted that ministers to the sick are allowed to take the same precautions against potential infection as medical professionals. Other accommodations that are allowed include the use of a sterile container of oil that is separate from the normal stock of oil a priest would use for the sacrament and disposal prayer sheets that can be discarded of with other biohazardous material. There are also allowances for providing the "Rite for Emergency" when death is imminent.¹

Opportunity for Outreach and Education
But while Catholic hospitals and dioceses quickly implemented such protocols or formed specially trained teams of priest chaplains to meet the needs of patients requesting these sacraments, most non-Catholic hospitals did not.² Instead, stories began to emerge that clergy were being denied admittance to COVID positive patients, and in some cases even denied access to non-positive patients because they were roomed on floors deemed as "COVID units" during the worst of the outbreak. And while several of these cases were eventually settled by the Office for Civil Rights (OCR) at the U.S Department of Health and Human Services as incidents of religious discrimination, the more important issue was that many members of the faithful were not able to receive end-of-life sacraments at the time of their death.³

Early in the pandemic, my Office of Catholic Health Care for the Diocese of Kansas City-St. Joseph was contacted by a local health care ethics consortium to record an interview for the city's medical community about Catholic perspectives on end-of-life care, and specifically our beliefs related to sacramental care of the dying. Several of the area's non-Catholic hospitals had encountered families outraged that their loved ones had been denied these sacraments before they died, and members of their Spiritual Care Departments were contacting the ethics group to see if they knew what the problem was with these Catholic families. It was noted that other religious denominations recognized the threat of contagion and spreading COVID-19 and accepted (albeit reluctantly) that they could not be with patients in their rooms, but the Catholic families did not always accept this reality. The diocese had also received a few calls from members of the faithful who did not understand why their parish priests were being refused admittance to local hospitals to visit and anoint dying family members (even a few clergy called in this regard). We further discovered — much to our surprise — that in our two, area Catholic facilities patients were not allowed to receive these sacraments when the priest chaplains were unavailable, and parish priests were being denied pastoral visits, because many of our non-Catholic staff had similar views to those noted above and concluded these sacraments simply could not be provided by outside clergy due to the risks posed by COVID-19. The request for an interview with this local ethics consortium then provided a much-needed opportunity for outreach and education regarding these important matters for the Catholic faithful.

In arranging the interview with the ethics group, as well as through investigating the situation in our Catholic hospitals, it was soon discovered that most non-Catholic chaplains and medical professionals did not fully understand the Catholic view of sacraments, nor appreciate the specifics of how these rites must be conducted for them to be considered valid. For example, people I spoke with did not understand that the end-of-life sacraments can only be performed by a priest who must be physically present with the patient — after all, all religions who believe in prayer know that prayer can work at a distance, so some chaplains and hospital personnel had wondered why the priest could not simply do the sacrament from a waiting room where there would be no fear of infection, or even simply pray for the dying person in their Church. In addition, the concrete, visible signs of the sacrament were not understood, such as the oil that is used for the anointing. Another dimension that was overlooked by many non-Catholics was the real meaning of a sacrament such as "anointing of the sick" for a patient who was not simply sick, but who was clearly dying. Our belief in "spiritual healing" and the opportunity that can be provided for reconciliation with God before death through these rites were not fully appreciated by members of different faiths.

And so, in the interview which was conducted in May of 2020 I was able to clarify the Catholic perspective on sacramentality, emphasize the importance of these rites for faithful Catholics desirous of them when facing the threat of death, and the allowances that can be made to the rite for its safe provision or in emergent situations. The diocese also provided instructional documents from the USCCB and CHA that clarified all of these points to be shared with hospital chaplains and health care professionals, and to provide a better context for understanding the requests of patients and families for these sacraments. My Office was also able to provide specific education for our two Catholic hospitals through their Ethics Committee about the importance of these sacraments, and the need to make every accommodation possible for their provision when requested. We also worked with our Catholic hospitals to train several priests on how to conduct the rites safely and properly don PPE, who have then been serving as resources for our local hospitals. We also made sure to communicate all of this to the priests of the diocese, so that they understood the concerns of the local hospitals, as well as how to arrange for one of the priests who had been trained to visit sick or dying parishioners in facilities with visiting restrictions and COVID-19 protocols. The goal was to find a balance between respecting the necessary protocols in pace and the faith beliefs of Catholics.

The Need for Ongoing Education for Both Catholics and Non-Catholics
Since May of 2020, there have still been reports of incidents in our area in which the provision of Catholic end-of-life sacraments were not allowed. In some cases, the reason for not allowing the sacramental visit still stemmed from a lack of understanding of the importance of such rites in the lives of Catholics, or a lack of understanding of the manner in which the sacrament can be safely provided — and so, ongoing education remains a priority.

However, other situations genuinely seemed to be ones in which the sacrament could not be safely provided or a priest with the proper safety training was not available. But it is important to recognize that there are many instances in which Catholics who would desire the end-of-life sacraments are unable to receive them — such as when death is sudden or unexpected. The Church, in her wisdom, accounts for these cases, but we recognized that education was needed for laity on the Church's perspective regarding the death of the faithful who do not receive the end-of-life sacraments. While every effort should be made to provide these rites for Catholics who are dying, the United States Conference of Catholic Bishops and groups such as the CHA provide guidance that when this is not possible a priest, "can provide the patient the prayer of the Church, prayers for a dying person, the prayer of Apostolic Pardon, and the assurance of the Plenary Indulgence granted the person with COVID-19."⁴ Many families who were distraught to find out that their loved ones died without the benefit of the end-of-life sacraments were greatly relieved and spiritually uplifted to learn about the Apostolic Pardon and the Plenary Indulgence, as well as being reminded of the value of their own prayers, united with those of the Church, for all of the dead.⁵ These key elements of our faith are especially important to recall as we continue to struggle through this pandemic.

Conclusion
The impact of COVID-19 on end-of-life sacramental care highlighted the importance of good communication with non-Catholic members of our hospital staffs, reminding us that while many non-Catholics have joined us in this health care ministry, that does not mean they understand all of the intricacies of the sacramental life of the Church. In retrospect this idea is obvious, but in the midst of everything that the pandemic has thrown at the world it is clearly something that was easily overlooked — though not intentionally — and needed to be addressed.

But the invitation by the local ethics consortium to address end-of-life sacramental care for Catholics also highlighted the importance of communicating these important values and beliefs to other health care providers for the good of all the faithful in our diocese. Once again, it is obvious that Catholics in our area go to non-Catholic hospitals, and yet they were being impacted as well by the lack of these sacraments. The Office of Catholic Health Care and the Spiritual Care Departments of our two Catholic hospitals were able to work together to provide educational information about end-of-life sacramental care in the Catholic Tradition for these other hospitals.

This experience serves as an important reminder that Catholic Ethicists can use our knowledge and skill to enrich not only the facilities we work for, but we can also have a positive impact on the communities where we are located when we remember to look beyond the walls of our own hospitals.

John F. Morris, Ph.D.
Director of Catholic Health Care
Diocese of Kansas City - St. Joseph
Kansas City, Kansas
[email protected]

ENDNOTES

1. Catholic Health Association of the United States, "Reminder of the Fundamentals for the Sacrament of the Anointing of the Sick," available online at: https://www.chausa.org/docs/default-source/default-document-library/sacrament-of-anointing-3-25-20.pdf.
2. See Maria Wiering, "Archdiocese forming team of priests trained to anoint Catholics dying of COVID-19," April 20, 2020, The Catholic Spirit, available online at: https://thecatholicspirit.com/news/local-news/archdiocese-forming-team-of-priests-trained-to-anoint-catholics-dying-of-covid-19/.
3. United States Department of Health and Human Services, "OCR Resolves Religious Discrimination Complaints after Maryland and Virginia Hospitals Ensure Patients Can Receive Safe Religious Visitations During COVID-19," Press Release October 20, 2020, available online at: https://public3.pagefreezer.com/content/HHS.gov/31-12-2020T08:51/https://www.hhs.gov/about/news/2020/10/20/ocr-resolves-religious-discrimination-complaints-after-maryland-and-virginia-hospitals-ensure.html.
4. Catholic Health Association of the United States, "Questions and Answers regarding sacramental practice during the COVID-19 Pandemic, Updated 3/31/2020," Available online at: https://www.chausa.org/docs/default-source/default-document-library/qa-regarding-sacramental-practice-during-the-covid-3-31-20-(002)15289af4dff26ff58685ff00005b1bf3.pdf?sfvrsn=0.
5. For more information on the Apostolic Pardon see the CHA document, "Reminder of the Fundamentals for the Sacrament of the Anointing of the Sick" or the Pastoral Care of the Sick: Rites of Anointing and Viaticum, III, "Rites for Exceptional Circumstances." For more on the Plenary Indulgence see," Decree of the Apostolic Penitentiary on the granting of special Indulgences to the faithful in the current pandemic, 20.03.2020" available online at: https://press.vatican.va/content/salastampa/en/bollettino/pubblico/2020/03/20/200320c.html.