BY: FR. MICHAEL D. PLACE, STD
Fr. Place is president and chief executive officer, Catholic Health Association,
St. Louis.
I am writing this on a flight home from Rome, where I attended the 19th International
Conference of the Pontifical Council for Health Pastoral Care. Before and after
the conference, the continental delegates who constitute the board of the International
Federation of Catholic Health Associations (AISAC) met. I will begin with a
few observations on the AISAC meeting and then turn to the conference's subject:
palliative care.
AISAC
A regular component of the AISAC agenda is a report by each delegate on the
condition of Catholic health care in his or her part of the world. For me, it
is always an opportunity to expand my appreciation of the rich and diverse nature
of the ministry across the world. Although these reports are never short on
problems, this year's reports were quite sobering. While there was great variety
in the specific matters discussed, the general conclusion was that Catholic
health care was experiencing a time of significant challenge to its ability
to maintain its identity.
As a result of our discussion, it was agreed that two of the delegates will
prepare a "basic text" (we Americans would most likely call it a "white
paper") that would, first, characterize the themes common to the international
experience of the health care ministry and, second, outline some initial opportunities
for collaboration. Reflecting on our conversations, I would expect the "basic
text" to consider health issues, such as the pandemic of HIV/AIDS; delivery
issues, such as the cost of pharmaceuticals; economic issues associated with
the increasing commodification of health care delivery; public policy issues
resulting from the increasing cost of health care and the desire of many governments
to realign existing government responsibility for supporting access to health
care services; ecclesial issues, such as relations with bishops and episcopal
conferences; leadership issues often associated with the changing demographics
of religious life; and structural issues concerning the best ways to organize
and manage the ministry civilly and ecclesially.
Although it will not be easy to provide coherence to the dimensions of these
issues, all of which are held in common, it will be still more difficult to
discern the "value added" opportunities for common or shared activities.
The possibility of such activity will not be new to Catholic health care in
the United States. We are aware of the activities of Catholic Relief Services
and the Catholic Medical Mission Board. In addition, within the ministry, there
is the Catholic Consortium for International Health Care, a U.S.-based effort
to support health care in the Third World. Many institutions and systems also
provide opportunities for medical "missions" to various nations. At
issue now will be whether, in addition to these activities, there will be other
opportunities for international solidarity within the ministry. Stay tuned!
Palliative Care
Now to the International Conference: The attendance at this year's meeting
was significantly higher than in recent years. There also were more practitioners,
particularly nurses, from across the world. Clearly, the topic addressed a very
real need.
As I reflect on two and a half days of talks (dialogue was not part of the
conference agenda), there are three aspects, among the points of discussion,
that I would like to highlight.
Consensus Regarding the Challenge Unlike some international meetings,
in which much time can be spent debating definitions and defining the problem,
this meeting got quickly down to business. One explanation for this clarity
is the significant role the World Health Organization (WHO) plays in much of
the world. While we Americans tend to rely on our federal health agencies for
expertise and guidance, much of the world-most especially developing nations-rely
on WHO. For WHO, increasing access to palliative care is an international priority.
What I found quite interesting was the holistic approach to palliative care
taken by WHO and others. Palliative care is commonly understood to include the
improvement of quality of life on the part of a patient and family facing life-threatening
illness through the relief of suffering by addressing the physical and psychological
needs of patient, family, and caregivers. Palliative care's focus also
goes beyond death to include bereavement. Though this expansive definition would
not include control of pain not associated with life-threatening illness, conference
speakers proposed that tens of millions of persons across the globe would benefit
from palliative care. In fact, one speaker argued that few people who
need palliative care actually receive it.
As for why this is the case, the international analysis, as summed up by conference
speakers, was strikingly similar to what advocates of palliative care in the
United States speak of as barriers: lack of political support, social prejudices,
the size of the affected population, limited health care resources, deficiencies
in the training of health care professionals, and legal and regulatory barriers
to providing medications-especially opioids.
In considering these barriers, a speaker proposed that the effective provision
of palliative care should be viewed as a public health problem that requires
a comprehensive, population-based solution. Components of such a comprehensive
approach would include influencing government policies and priorities, developing
and providing effective educational and training programs, making needed medications
available, and providing home-based care.
In light of our Fall Member Strategy Sessions, I found the framing of the issue
as a public health problem to be quite provocative. While it is not clear how
your board will prioritize our strategic and transformational activities for
the next three years, board members are aware that the challenges facing aging
services and palliative care arose in all three sessions. Whether palliative
care becomes a signature activity for us as national ministry gathered and engaged,
it already is a priority for many in the ministry. Perhaps some of the international
discussions will be of help.
A Theology of Pain and Suffering Not surprisingly, the conference devoted
some attention to how we, as believers, approach the reality of pain and suffering.
The intent was not to minimize the importance of palliative care, but, rather,
to highlight the fact that, even if all people in need of palliative care were
to receive it (and, as we know, they do not), the reality of pain and suffering
would remain. This means that, for the believer, at least two fundamental faith
questions will arise: Why do I experience pain and suffering if my God loves
me? What is the spiritual meaning for that pain and suffering?
Although Pope John Paul II has provided a contemporary perspective on pain
and suffering in his apostolic letter Salvifici Doloris, I would dare
to suggest that we lack a coherent contemporary pastoral understanding of pain
and suffering. Although the acute care clinical setting is not the most apt
environment for presenting a catechism on pain and suffering, such a setting
would be enriched by an ethos that could help caregivers explain, to some patients,
what medicine is not able to do for them, and, to other patients, why
medically successful outcomes do not always eliminate pain or suffering.
Such an ethos might be even more helpful in our continuum of care services,
where caregivers tend to have contact with those they serve for longer periods
of time. Pastoral care certainly has responsibilities in this area, but, I would
suggest, a theological understanding of pain and suffering is central to the
mission of Catholic health care itself. How we might go about gaining such a
pastoral perspective is a provocative challenge.
Sacrament of the Sick and Palliative Care Another of the conference
papers reflected on the Sacrament of the Sick and palliative care. Perhaps because
of my personal interest in liturgy and my theological training, I was particularly
impressed by the theological and pastoral dimensions of this presentation. In
listening to it, I was reminded of the support CHA provided the National Association
of Catholic Chaplains for a project on the Sacrament of the Sick, which included
dialogue with diocesan bishops. While I know that the resources developed for
this initiative were quite good, I do not know what impact they have had in
the acute care setting. I know even less about their impact on the continuum-of-care
setting. Perhaps this is another topic we could pursue. Earlier I posed questions
about the meaning or spirituality we bring as we provide palliative and other
care; we also could benefit from discussing what prayer we bring as a sacramental
people.
Without entering into that discussion here, I would like to share an evocative
image. One of the components of the rituals associated with the Sacrament of
the Sick is Viaticum. Intended for the person who has entered the final stage
of the dying process, Viaticum can include the celebration of the Sacrament
of the Sick, but it also includes reception of Holy Communion and the community
of faith's final blessing. While I have often heard of receiving the Eucharist
described as "food for the journey," at the conference I heard about
an image that was new to me: "In the celebration of Viaticum, we commend
the person for whom and with whom we pray from our loving embrace to the loving
embrace of an 'eternal family.'" As I heard that description, I wondered
how many patients in acute care or the continuum of care had that image available
to them. If they did, what difference might it make?
A Papal Allocution
In drawing this column to a close, let me offer a relevant excerpt from John
Paul II's allocution to the conference:
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 forgo 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.
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.
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 forgo
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.
To provide this help in its different forms, it is necessary to encourage
the training of specialists in palliative care at special teaching institutes
where psychologists and health-care workers can also be involved.
Hopefully, the pope's reflections will be helpful to the ministry and, in particular,
to those who work in palliative care.