CPR (Cardiopulmonary Resuscitation) in the age of Covid 19-What You Need to Know

Several years ago, a nurse friend was with her boyfriend at a concert hall when he collapsed with no heartbeat or breathing. She called for 911, started CPR and asked for an AED (automatic external defibrillator) , which is located in most offices and public buildings. An AED is a sophisticated, yet easy-to-use (even for a lay person with training), medical device that can analyze the heart’s rhythm and, if necessary, deliver an electrical shock, or defibrillation, to help the heart re-establish an effective rhythm.

However, the concert staff didn’t know where it’s AED was.

My friend continued to deliver mouth to mouth an chest compressions while a crowd gathered, some of whom were physicians who told her to stop because it was hopeless.

Finally, an ambulance arrived and took the boyfriend to a local hospital. He not only survived but was discharged 3 days later in good condition and determined to start a healthier lifestyle.

So I was stunned to read an April 21, 202 New York Post article “NY issues do-not-resuscitate guideline for cardiac patients amid coronavirus” (Covid 19) that said New York state had just issued “a drastic new guideline urging emergency services workers not to bother trying to revive anyone without a pulse when they get to a scene, amid an overload of coronavirus patients.” (Emphasis added)

While paramedics were previously told to spend up to 20 minutes trying to resuscitate a person in cardiac arrest, the new guideline was deemed “necessary during the COVID-19 response to protect the health and safety of EMS providers by limiting their exposure, conserve resources, and ensure optimal use of equipment to save the greatest number of lives.’’

First responders were outraged and their union leader said “Our job is to bring patients back to life. This guideline takes that away from us.”

Earlier this month, the Regional Emergency Services Council of New York had issued a new guideline that said cardiac arrest patients whose hearts can’t be restarted at the scene should no longer be taken to the hospital for further life-saving attempts because the city hospitals had been “inundated with dying coronavirus patients to the point where there are frequently no ICU beds.”

One paramedic acknowledged that only a small percentage of people in cardiac arrest-3 or 4 out of 100-are brought back to life through  CPR and other aggressive interventions such as drugs and hospitalization but insisted that “for those three or four people, it’s a big deal.”

On April 22 and just hours after the initial New York Post article was published, the new guidelines were rescinded. New York City’s Fire Department and first responders never adopted the no-revival directive from the state and kept using the traditional 20-minute policy.

WOULD YOU KNOW WHAT TO DO IF SOMEONE COLLAPSES WITH NO HEARTBEAT OR BREATHING?

When I started as a nurse in many decades ago, we were trained in CPR and taught how to use AMBU bags (mask, valve and self-inflating bag) to breathe for patients in arrest or distress in place of mouth to mouth resuscitation. AMBU bags are now standard equipment on ambulances and other rescue services.

Over the years, techniques for CPR changed especially in 2008 when the American Heart Association released new recommendations that bystanders can skip mouth to mouth resuscitation and use “Hands-Only CPR” to help an adult who suddenly collapses:

“In Hands-Only CPR, bystanders dial 9-1-1 and provide high-quality chest compressions by pushing hard and fast in the center of the victim’s chest.”

Now, the Covid 19 pandemic has changed CPR guidelines.

As the April 16, 2020 Notre Dame Fire Department concisely explains on pandemic-modified CPR guidelines for bystanders:

“Bystander CPR (cardiopulmonary resuscitation) improves the likelihood of an individual’s survival from cardiac arrest occurring outside of the hospital. However, coronavirus is spread through respiratory droplets when an infected person coughs, sneezes or talks. If a rescuer breathes into a cardiac arrest individual’s mouth, there will likely be an exchange of respiratory droplets. Household members who have been exposed to the individual at home should not hesitate to attempt life-saving rescue measures.

A non-household bystander who attempts to rescue a cardiac arrest individual should wear a face mask or cloth over his/her mouth and nose and place a face mask or cloth over the mouth and nose of the individual to reduce the risk of transmission.

In the case of an adult in cardiac arrest, lay rescuers should perform at least hands-only CPR. For children, lay rescuers should perform chest compressions and consider mouth-to-mouth ventilation, if willing and able, given the higher incidence of respiratory arrest in children.

To perform Hands-Only CPR, you place your hands in the center of the chest and pump hard and fast at a rate of 100 to 120 compressions per minute.

If an AED (automated external defibrillator) is available, please proceed with opening the AED and following the automated prompts to initiate life-saving intervention. Defibrillation is not expected to be a highly aerosolizing procedure. If an AED is not available, please proceed with Hands-Only CPR.

For all cardiac related emergencies, EMS (911) should be called…For more information, refer to the American Heart Association’s interim CPR guidance.

CONCLUSION

As a nurse, I have participated in many instances of cardiac or respiratory arrest and it’s always stressful. However, the joy of participating in saving someone’s life is indescribable. And even when we were unsuccessful, we had the consolation of knowing that we did everything we could for that person.

I encourage everyone to take a course to learn CPR. To find such a course, you can contact your local hospital or go to the American Heart Association’s Find A Course  or to the Red Cross website.

And I personally thank the courageous New York Fire Department and first responders for upholding the standards of care for all their patients.

 

Health Care Rationing, Covid 19 and the Medical Ethics Response

While the key medical model in the US for Covid 19 deaths has just again been revised from 240,000 to 100,000 to now just 60,000 by August along with concerns about the possible overuse of ventilators in Covid 19, there is still a push for medical health care rationing guidelines.

As the April 8, 2020 Wall Street Journal article As Coronavirus Peaks, New York City’s Hospitals Prepare ‘Live or Die’ Guidance” notes, some hospitals and health care systems are coming up with guidelines and scoring systems to allocate ventilators. At the same time, New York lawmakers have recently passed a measure to protect hospitals and clinicians from certain medical malpractice lawsuits while the Covid 19 virus strains the health system.

Disability groups are complaining about discrimination in health care rationing plans that would “illegally deprive people based on age, mental cognition or disability”. In addition, a recent Center for Public Integrity analysis shows that policies in 25 states would ration care in ways disability advocates have denounced.

While such rationing plans are usually said to be based on determining which patients have little if any chance of a good outcome, i.e.  medical futility, even the American Medical Association has admitted in its Code of Ethics that “However, physicians must remember that it is not possible to offer a single, universal definition of futility. The meaning of the term “futile” depends on the values and goals of a particular patient in specific clinical circumstances.” (Emphasis added)

THE CATHOLIC MEDICAL ETHICS PERSPECTIVE

Medical ethics in Catholic health care institutions are often considered the most stringent in terms of protecting human life from conception to natural death. So what do Catholic ethics authorities say about rationing?

On April 3, 2020, the US Catholic Conference of Bishops (USCCB) issued a powerful statement “Bishop Chairmen Issue Statement on Rationing Protocols by Health Care Professionals in Response to Covid-19” that stated:

“Every crisis produces fear, and the COVID-19 pandemic is no exception. However, this is not a time to sideline our ethical and moral principles. It is a time to uphold them ever more strongly, for they will critically assist us in steering through these trying times.”

and

“Good and just stewardship of resources cannot include ignoring those on the periphery of society, but must serve the common good of all, without categorically excluding people based on ability, financial resources, age, immigration status, or race.” (Emphasis added)

The statement cited other Catholic health care groups like Catholic Medical Association, the National Association of Catholic Nurses and the National Catholic Bioethics Center that all issued helpful statements.

However another Catholic group mentioned, the Catholic Health Association, has also issued a problematic statement on the rationing issue titled “Code Status and COVID-19 Patients “ stating that:

“CPR may be medically inappropriate in a significant portion of elderly, critically ill patients with COVID-19 and underlying comorbidities. As per Parts 3 and 5 of the Ethical and Religious Directives for Catholic Health Care Services, if it is shown that the burdens exceed the benefits, it is morally acceptable to withhold such procedure.” (Emphasis added)

And even worse:

“If treating clinicians, including more than one physician, determine that CPR is not medically appropriate, a Do Not Attempt Resuscitation Order (DNR) may be written without explicit patient or family consent.” (All emphasis added)

In a separate April 7, 2020 statement from the  National Catholic Partnership on Disability titled “Rights of Persons with Disabilities to Medical Treatment During the COVID-19 Pandemic , the NCPD states “As The Office of Civil Rights of the U.S. Department of Health and Human Services has recently reminded us, America’s basic civil rights laws, including the Americans with Disabilities Act, prohibit discrimination:

“[P]ersons with disabilities should not be denied medical care on the basis of stereotypes, assessments of quality of life, or judgments about a person’s relative ‘worth’ based on the presence or absence of disabilities. ”  (Emphasis added)

CONCLUSION

Over my many decades as a nurse, I have seen the question of “quality of life” deteriorate from what can we do to improve the quality of life for every patient to judging whether or not a patient has sufficient quality of life to justify treatment or care like a feeding tube.

During that time, Alzheimer’s and major CVAs (strokes) in advanced age have come to be seen as fates worse than death that should not be a burden on people and their families or a waste of health care resources.

Before my own mother developed Alzheimer’s and a terminal cancer, she often told me that she never wanted to be a “burden to her family”. I never considered her a “burden” when I cared for her and she was comfortable and fed to her last day. I will never tell my children what my mother told me.

And especially with assisted suicide polls showing much public support, we cannot afford to play into the idea that some people are “better off dead” regardless of whether or not they “choose” a premature death or someone else “chooses” it for them.

We should also remember the lethal legacy of the 2005 Hurricane Katrina disaster. Flooding caused the New Orleans mayor to issue an unprecedented mandatory evacuation of the city with the exception of major hospitals. But when conditions worsened at the large Memorial Medical Center and evacuation efforts were slow, some medical staff allegedly euthanized some of the patients.

However and despite strong evidence, a massive PR campaign portraying those patient deaths as “compassionate” resulted in the 2007 grand jury refusing to indict the doctor and 2 nurses charged.

As we see this debate over medical ethics in crisis situations continue today, we must continue to insist that every person deserves a natural lifespan without discrimination.

Ventilator Rationing, Universal DNRs and Covid 19 (Coronavirus)

As a nurse myself, it is hard to watch my fellow nurses bravely fighting on the front lines of this pandemic without being able to be there with them.

Nurses are a special breed. In my over 50 years as a nurse, I found that most of us chose nursing because we want to help people and alleviate suffering. We work the long hours on our feet, skip meals, hold hands and listen, cry when our patients die, etc. because we truly do care.

But the health care system has been changing. A dark new ethics movement is infecting our system and telling us not only that our patients have a right to choose to end their lives but also that some of our patients even “need” to die and that we can’t care for all of them during the Covid 19 pandemic.

Worst of all, we are being told that we can now know how to decide which patients are “expendable”.

VENTILATOR RATIONING

A 71 year old man with a heart condition arrives at a hospital is diagnosed with Covid 19. His condition worsens and he is placed on a ventilator to help him breathe. Then the infection rate spikes in the city and the hospital is overrun with severely ill patients, many between 20 and 50 years old and otherwise healthy.

The health care team is forced to decide which patients should they focus on and care for.

This is the scenario posed in a March 20, 2020 Medpage article “Ethics Consult: Take Elderly COVID-19 Patient Off Ventilator?— You make the call” along with an online survey with 3 questions:

1. Would you prioritize the care of healthier and younger patients and shift the ventilator from the elderly man to patients with a higher probability of recovering?
2. Would you change your decision if the elderly patient had been in intensive care for a non-COVID-19-related illness?
3. Would you prioritize the older man over college students who had likely been
infected during spring break trips?

After almost 4000 votes, the survey showed 55.65% voting yes on prioritizing the care of the healthier and younger patients, 78.11% voting no on changing their decision about the elderly patient if he didn’t have Covid 19 and 71.12% voting no on prioritizing the elderly man over college students likely to have been infected on a spring break trip.

So while most people fear becoming infected with Covid 19, less well-known ethical dangers may also affect us-especially those of us who are older or debilitated.

Every day, we hear about the shortage of ventilators needed for Covid 19 patients and the overworked and understaffed health care professionals providing the care. Now both mainstream media and medical journals are publishing articles about the ethical dilemma of denying CPR (cardiopulmonary resuscitation) or a ventilator to older patients or those with a poor prognosis with Covid 19 in a triage situation.

Triage is defined as “A process for sorting injured people into groups based on their need for or likely benefit from immediate medical treatment. Triage is used in hospital emergency rooms, on battlefields, and at disaster sites when limited medical resources must be allocated.” (Emphasis added)

But this definition does NOT include deciding how to triage people based on age or “productivity”.

UNIVERSAL DNRs

A March 25, 2020 Washington Post article “A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic” posed the question: “how to weigh the ‘save at all costs’ approach to resuscitating a dying patient against the real danger of exposing doctors and nurses to the contagion of coronavirus.”

This is not just an academic discussion.

As the article reveals, “Northwestern Memorial Hospital in Chicago has been discussing a do-not-resuscitate policy for infected patients, regardless of the wishes of the patient or their family members — a wrenching decision to prioritize the lives of the many over the one.” (Emphasis added) And Lewis Kaplan, president of the Society of Critical Care Medicine and a University of Pennsylvania surgeon, described how colleagues at different institutions are sharing draft policies to address their changed reality.

Bioethicist Scott Halpern at the University of Pennsylvania is cited as the author of one widely circulated model guideline being considered by many hospitals. In an interview, he said a universal DNR for Covid 19 patients was too “draconian” and could sacrifice a young person in otherwise good health. He also noted that the reality of health-care workers with limited protective equipment cannot be ignored. “If we risk their well-being in service of one patient, we detract from the care of future patients, which is unfair,” he said.

The article notes that “Halpern’s document calls for two physicians, the one directly taking care of a patient and one who is not, to sign off on do-not-resuscitate orders. They must document the reason for the decision, and the family must be informed but does not have to agree.” (Emphasis added)

This could not only upend traditional ethics but also the law as “Health-care providers are bound by oath — and in some states, by law — to do everything they can within the bounds of modern technology to save a patient’s life, absent an order, such as a DNR, to do otherwise.”

Both disability and pro-life groups have condemned such health care rationing with Covid 19, especially for older people and people with disabilities.

However, this and more is apparently already happening.

In an April 1, 2020 Wall Street Journal article “What the Nurses See: Bronx Hospital Reels as Coronavirus Swamps New York” a co-worker told the nurse interviewed that the nurses were no longer doing chest compressions to resuscitate Covid 19 patients because “it uses lots of protective gear and puts workers at greater risk than chemical resuscitations”. This was corroborated by other nurses who said this has become an “unspoken rule.”

CONCLUSION

How can we protect ourselves and our loved ones in these circumstances?

At the very least and whether or not we are older or have disabilities, we should consider or reconsider our advance directives.

As the Life Legal Defence Foundation  writes in their “SPECIAL MESSAGE ABOUT COVID-19 AND ADVANCE HEALTH CARE DIRECTIVES”:

As COVID-19 spreads around the globe, the public is learning about the importance of mechanical ventilators in providing temporary breathing support for many of those infected. Ventilators are saving lives!

A false understanding of respirators and ventilators has become commonplace in recent years. Many people think that these and similar machines’ only role is prolonging the dying process. The widely publicized treatment of COVID-19 patients is helping to dispel that myth. Many patients rely on machines temporarily every day for any number of reasons and go on to make full recoveries.

Unfortunately, many individuals have completed advance health care directives stating or suggesting that they do not wish to receive breathing assistance through mechanical ventilation.

Please take the time to review any advanced medical directives (including POLST forms) signed by you or your loved ones to make sure they are clear that mechanical ventilation is not among the forms of care that are refused. If there is any ambiguity, you may want to consider writing, signing, and dating an addendum specifying that mechanical ventilation is authorized. (Emphasis in original)

I would add that other treatments or care such as DNRs and feeding tubes also not be automatically checked off. I believe it is safer to appoint a trusted person to insist on being given all information concerning risks and benefit before permission is given to withdraw or withhold treatment.

Even as the nation is racing to get more ventilators and staff as we cope with this terrible pandemic, we all must continue to affirm the value of EVERY human life.

 

Is Abortion More Important than Safety? The Case Now Before the US Supreme Court

In 1986, Missouri became the first state to pass an abortion law requiring abortion doctors to have admitting privileges at a hospital “in the community” to ensure the health and safety of women undergoing abortion.

Later, I was horrified to find out that a doctor was doing abortions just a few miles from my home in St. Louis. It turned out that his admitting privileges were in another country! The abortion clinic was closed.

As I wrote last August in “Pro-abortion Desperation in Missouri” :

“the last abortion clinic in Missouri lost its license because of numerous health and safety violations. The Planned Parenthood abortion clinic continues to operate only because of several temporary injunctions by a judge.”

While the Missouri case is still ongoing, now the US Supreme Court is hearing arguments in the June Medical Services v. Russo case concerning whether Louisiana’s law requiring abortion providers to have admitting privileges at a local hospital conflicts with the Court’s 2016 Whole Woman’s Health v. Hellerstedt decision along with a second issue about “whether abortion providers can legally represent the interests of women seeking an abortion when those providers sue to overthrow laws protecting those women’s health and safety.”

IS ABORTION MORE IMPORTANT THAN SAFETY?

In a powerful commentary titled “The OB-GYNs Who Play Politics With Women’s Lives-Abortion is more important than safety to the American College of Obstetricians and Gynecologists” in the March 3, 2020 Wall Street Journal, Dr. Christina Francis calls out the American College of Obstetricians and Gynecologists (ACOG) for “offering a medically unsound recommendation in the furtherance of its extreme position on abortion”.

Dr. Francis, a board-certified obstetrician-gynecologist and the chairman of the board of the American Association of Prolife OB/GYNS, refutes ACOG’s friend of the court brief arguing that the admitting privileges requirement for abortionists is not “‘medically justified’ and therefore constitutes an ‘undue burden’ on a woman’s right to abortion'” by stating:

“Yet every second counts in an obstetric emergency. A pregnant woman experiencing severe uterine hemorrhage can bleed to death in as little as 10 minutes. That’s why its essential that anyone performing an abortion have the ability to admit a patient to a nearby hospital—preferably one closer than 30 miles away.”

ACOG routinely puts politics ahead of medicine by adopting the most extreme positions on abortion. It has lobbied and briefed against parental notification of minors and informed-consent laws, and in favor of taxpayer-funded abortion. It has advocated for laws restricting speech around clinics and compelling pro-life pregnancy centers to tell women where they can go to obtain state-subsidized abortions. ACOG’s work has gotten so political that in 2008 it added a lobbying arm. I was refused when I asked if I could direct our dues only to the organization’s nonlobbying arm.

Eighty-six percent of OB-GYNs don’t perform abortions, but ACOG’s position is that you either support the most extreme abortion lobbying or you’re off the island. Most of ACOG’s abortion advocacy is undertaken free of consultation with its almost 60,000 members. Physicians who’ve left the organization, like me, support its general work but don’t want to support abortion lobbying, especially when it comes to watering down or eliminating safety standards. (Emphasis added)

Dr. Ford also notes that:

“In any practice area other than abortion, a doctor performing an operation would have hospital-admitting privileges. In the case of complications that doctor would, at a minimum, call ahead to fast-track the patient to the appropriate emergency care. Abortion-clinic patients, on the other hand, are frequently kicked to the curb and told to make their own way to the emergency room.”

CONCLUSION

Those of us in Missouri have seen the problems and attempted coverups at the hopefully last Planned Parenthood clinic in St. Louis.  Just last year, it was reported that:

“Operation Rescue, with the help of Missouri pro-life activists, has documented 74 medical emergencies that have occurred at RHS Planned Parenthood in the past ten years, including three emergencies that required ambulance transport for women to a local hospital within a 22-day period ending on May 15, 2019.” (Emphasis added) 

The Supreme Court decision is not expected until June and is likely to have an enormous impact on the state of abortion in our country, especially since pro-abortion groups have now abandoned the old rhetoric about keeping abortion “safe, legal and rare'” in favor of tax-payer funded abortion on demand up to birth and even leaving babies to die after failed abortions.

In the meantime, considering choosing and supporting pro-life health care professionals and their professional organizations such as the American Association of Pro-life Obstetricians and Gynecologists (AAPLOG) and the National Association of Pro-life Nurses (NAPN).

Can a POLST be Hazardous to Your Life?

First, we had the “living wills” developed in the 1970s by the Euthanasia Society US (later renamed the Society for the Right to Die) to allow people to states their wishes for or-most importantly-against certain medical treatments in case they become unable to communicate their decisions. By 1991, The Patient Self-Determination Act was passed and every health care facility was required to ask every patient if they had such a document.

Today, we have many types of such documents including the newest one called the “Physician Orders for Life-Sustaining Treatment” (POLST)  that was developed in Oregon (the first state to legalize physician-assisted suicide) in 1991.

A POLST is a short document that people can carry with them with checkoffs for CPR (cardiopulmonary resuscitation) and tube feedings. And if the person is still alive but unable to communicate, the POLST has checkoffs for whether the person wants “Comfort measures only”, “Limited Interventions” like antibiotics and IV fluids, or “Full treatment”.

Although efforts to pass a national POLST law have failed so far, many states have passed their own versions that lead to serious concerns.

Most recently, Illinois is now considering a POLST bill SB 3524 that amends and expands the previous Health Care Surrogate Act.

Among the changes in the Illinois bill are changing “qualified physician” to “qualified health care practitioner” which  “means an individual who has personally examined the patient and who is an Illinois licensed physician, advanced practice registered nurse, physician assistant, or licensed resident after completion of one year in a qualified graduate medical education program”. (Emphasis added)

The bill also removes the requirement of a witness to the signature of the person, legal guardian or health care surrogate on the POLST form. This is an important requirement to be reasonably certain that the POLST reflects the person’s wishes.

The bill  defines a person’s “qualifying conditions” for a POLST as “Terminal condition”, “Permanent unconsciousness”, or “Incurable or irreversible condition” (a definition that alarms many disability groups).

The bill also defines “Life-sustaining treatment” as “any medical treatment, procedure, or intervention that, in the judgment of the attending physician, when applied to a patient with a qualifying condition, would not be effective to remove the qualifying condition or would serve only to prolong the dying process“. (Emphasis added)

Also, the bill states that the health care provider acting on the POLST in “good faith” is not “subject to any criminal or civil liability, except for willful and wanton misconduct, and may not be found to have committed an act of unprofessional conduct.” (Emphasis added)

A February 16, 2020 editorial in the Journal of the American Medical Association titled “Physician Orders for Life-Sustaining Treatment and Limiting Overtreatment at the End of Life” had this chilling observation about physicians’ attitudes and POLSTs:

Even with the best of counseling, some patients will refuse any limitations of treatment—36% of the patients in the study by Lee et al1 had POLSTs that indicated “full treatment,” presumably including admission to the ICU, mechanical ventilation, and cardiopulmonary resuscitation, if necessary. While receipt of these therapies would be considered POLST-concordant care, clinicians sometimes object to providing care that they perceive will be unbeneficial or even harmful. These conflicts between clinicians and patients or their surrogates are a common problem in ICU care and are seen as a major contributor to distress and frustration among clinicians.” (Emphasis added)

CONCLUSION

A 2013 article “The Problem with POLST – Physician Orders for Life-Sustaining Treatment” succinctly describes the problems with POLST and what we should instead be striving for:

“POLST only makes sense in cases of patients with terminal illnesses, in end stage disease with no real options. By that point in time there are no therapeutic treatment decisions to be made. Yet, a patient who is under treatment who is living with a disease, there are alternative treatment decisions to be made. There are risks to weigh and an up to date informed consent required. It cannot be left up to a patient to research new literature and evidenced based medical standards.

POLST even precludes an assessment by a paramedic to make any decisions on overall survivability at the time of emergency care in the field. Surrogate decision makers are not consulted, advance health directives are not read or considered, and second opinions are not sought. Intelligent and experienced assessments are precluded by POLST. In cases of non-terminal patients POLST does not respect society’s moral mandate to respect life and instead treats life cavalierly by simply pinning a card on a person’s chest with life and death decisions of timely and clear origin.” (Emphasis added)

As a former hospice, oncology and ICU nurse, I wholeheartedly agree!

Euthanasia: Canada, Conscience and Coercion

A January 22, 2020 CNA article titled Perform Euthanasia or Lose Government Funding”, Canadian Hospice Told” revealed that a secular Canadian hospice was at risk of losing its government funding over its refusal to euthanize patients who request an “assisted death.”

How could this happen?

First of all, Canadian health care (known to Canadians as “medicare”) is 69% publicly funded for “medically necessary” care administered by the 13 provinces and territories with different rules. 31% of Canadian health care costs are paid by the private sector for services not covered or only partially covered by medicare, such as prescription drugs, dentistry and optometry.

The problems started when the Canadian Supreme Court legalized MAiD (Medical Assitance in Dying” in 2015.

Soon after, the province of Quebec drew up guidelines for MAiD and made “euthanasia kits” for lethal injections available to every doctor in Quebec. Now most MAiD deaths in Canada are done by lethal injection.

In September 2016, about three months after euthanasia became legal in Canada, British Columbia’s Fraser Health Authority ( the publicly-funded organization responsible for administering healthcare in British Columbia) introduced a new policy which required all hospices receiving more than 50% of provincial funding for their beds to offer euthanasia to their residents. However, the hospice was operated by the non-profit organization the Delta Hospice Society, which is opposed to Canada’s MAiD

One doctor said that there are “‘strong lobbies’ backing this new effort to expand MAiD into additional institutions which receive provincial funding, including faith-based hospitals or hospices.(Emphasis added)

HOW ONE CATHOLIC HEALTH CARE FACILITY RESPONDED TO MAiD

Unfortunately and in 2018, the Catholic Covenant Health system in the province of Alberta, Canada released a revised MAID policy:

“after consultations with more than 100 individuals and groups including doctors, Catholic bishops, Alberta Health Services, the Alberta government, patient advisers, families, ethicists and community members.
Under the policy, witnessing and signing of legal documents and assessments of eligibility can take place on Covenant Health sites. Patients deemed eligible for MAID would still be transferred to other facilities.” (Emphasis added)

A current check of the Covenant website on MAiD shows no change in policy.

THE CANADIAN “SLIPPERY SLOPE” ALSO CONTINUES

In January, 2020 the Halifax Group, published “MAiD Legislation at a Crossroads: Persons with Mental Disorders as Their Sole Underlying Medical Condition” that supported MAiD not only for non-dying persons ” experiencing enduring, intolerable and irremediable suffering from physical conditions” but also for persons who have “a mental illness as their sole underlying medical condition.” (Emphasis added)

This month, The Expert Advisory Group responded to the Halifax group, warning that the Canadian medical suicide law is the “most permissive in the world”.

THE EFFECT OF MAiD ON DOCTORS AND NURSES

Last year, The Canadian Catholic Nurses joined the National Association of Catholic Nurses in opposing the American Nurses Association’s draft position for neutrality on physician-assisted suicide (unfortunately later approved) and gave a chilling look at what may be our future if legalized assisted suicide is not opposed:

“Our association formed in 2018 primarily in response to Canadian nurses’ moral distress regarding the nation-wide legalization of medically induced death.

Professional associations and licensing bodies across Canada endorsed the legal changes, requiring conscientious objectors to participate in “Medical Assistance in Dying” by “effective referral” to facilitate access at the patient’s request. Faith-based health care facilities are pressured to participate. Nurse practitioners are trained and qualified to prescribe and administer lethal doses of medication to patients that they or others deem eligible for euthanasia.”

and

The Canadian experience with assisted suicide and euthanasia provides evidence for your continued resistance to the practice.

Unlike Oregon, Canada has not experienced a growth in palliative care along with the rapid expansion of induced death. Instead, we experience ongoing demands for access to lethal injections for new categories of patients, including “mature minors;” those who write advanced directives; and those whose mental illness is the sole condition underlying their request.”

A 2018 study “Medical assistance in dying (MAiD): Canadian nurses’ experiences” stated that:

“It is vital to understand how MAiD is influencing nurses in the Canadian context to ensure a smooth transition of this end‐of‐life care option across settings and communities. ” (Emphasis added)

The study acknowledges some nurses’ “moral distress” but describes “how participating in, or declining to participate in MAiD is shaping the participants’ perceptions of nursing as a profession“. The authors suggest promoting concepts like “Providing holistic care without judgment, Advocating choice, Supporting a good death” to positively reinforce  that MAiD was “not a significant departure from their professional goals”. (Emphasis added)

(Ironically, 77% doctors in Laval, Canada refused to provide MAiD 18 months after legalization with the most common reason that MAiD was “too much of an emotional burden to bear”.)

CONCLUSION

Last year it was reported that More than one in every 100 deaths in Canada is administered by a doctor but that even this number is likely higher because parts of Canada currently do not report such deaths.

The numbers are also likely to get higher as the Canadian euthanasia laws expand the eligibility criteria and health care professionals worry about losing their jobs if they refuse to participate.

Unfortunately, most of the US mainstream media ignores the Canadian euthanasia experience while approvingly reporting on the increasing number of US states legalizing physician-assisted suicide.

What all of us need to understand is that the legalized killing of any patient ultimately leads to the destruction not only of the patient but also of a trustworthy health care system and a truly safe and civilized society.

Is there a “New” Catholic Medical Ethics?

A few years ago, a middle-aged prolife nurse friend of mine had a sudden cardiac arrest after her mother died but was resuscitated. She was taken to the same Catholic hospital where I received my nursing education. She wound up sedated and on a ventilator to help her breathe, along with a feeding tube. Her 24 year old son wanted all efforts made to save her and several of us volunteered to help if and when she returned home.

Instead and after a week or  two, her son was urged to remove her ventilator but, even then, she kept breathing even with the sedation medication used to control her tremors. But the son was horrified to see that her feeding tube was removed at the same time as the ventilator and against his wishes. The staff insisted that he agreed to this and that it was documented in the computer. He insisted he never agreed to this and demanded that the feeding tube be reinserted but the staff said they could not without a doctor’s order.

The son stayed for hours waiting for a doctor but the staff said the doctor was busy. A nurse from hospice came in and pushed for hospice but the son said he wanted to take his mother home eventually so he and the volunteers could care for her. The hospice nurse then told him that his mother was dying and her organs were failing.

I happened to be there at the time and, as a critical care nurse myself, I told the hospice nurse that I saw that my friend’s vital signs were normal and her kidneys were obviously functioning. I also questioned the dangerous increase in her sedation medication after her ventilator was removed because it could suppress her breathing. I was ignored. With a heavy heart, I lhad to leave to work my night nursing shift at another hospital but I told the son to call me if the doctor did not come.

The next morning, the son called me to tell me that the hospital just called to tell him his mother was dead.

He had stayed for several hours after I left but finally went home to get some sleep, thinking his mother was stable. He was devastated to later learn that his mother had been transferred to hospice against his wishes after he left. My friend then died a few hours later. She never got her a feeding tube or her sedation lowered or stopped. And she tragically died alone.

I still have nightmares about this.

THE “NEW” CATHOLIC MEDICAL ETHICS

While medically futile treatment has long been accepted as medically useless or gravely burdensome to the person, we now see a new bioethics with “quality of life”, economics, societal and family burdens, etc. included in the determination of medical futility.

This January, I was horrified to find that the influential Catholic magazine Commonweal published an article titled “Giving Doctors a Say-Futility and End-of-Life Ethics”  that also injects “respect for physicians as moral agents” to defend the rationale behind the (often secret) futility policies in Catholic hospitals  by citing cases like the Charlie Gard and Simon Crozier cases where medical care was removed from two infants with life-threatening conditions against the parents’ wishes.  In Charlie Gard’s case, the medical care was withdrawn by court order and in Simon Crozier’s case the medical care was withheld without the parents knowledge. Both boys died.

Tragically, the outrageous Simon Crosier case occurred in the same Catholic hospital where I once worked and where my daughter with Down Syndrome and a critical heart defect was made a Do Not Resuscitate behind my back and against my expressed wishes.

As a nurse and a mother, I was shocked by the Commonweal article but not surprised.

I have been writing about the deterioration in medical ethics even in Catholic institutions for many years.

In the Commonweal article, Michael Redinger (co-chair of the Program in Medical Ethics, Humanities at Western Michigan University , and Law} defends medical futility and criticizes the Simon’s Law passed in the Missouri legislature last year to prohibit “any health care facility or health care professional from instituting a do-not-resuscitate or similar order without the written or oral consent of at least one parent or legal guardian of a non-emancipated minor patient or resident”.  (Emphasis added)

Instead, Professor Redinger writes that “These efforts, collectively referred to as ‘Simon’s Law’ legislation, are well-intentioned but misguided”.

His Commonweal article concludes that:

“Given the coordinated efforts of Right to Life groups across the country and their ties to the Catholic Church, it is necessary to begin a broader conversation about the incompatibility of such laws with church teaching. Such a conversation would help guide individual Catholics at the end of life, and support Catholic bishops in their oversight of Catholic hospitals. Even better, it would relieve the medical staff at Catholic hospitals from the immense moral distress that comes from violating our oath to do no harm.” (Emphasis added)

 

HOW COULD THIS HAPPEN?

After years of research and my own experiences with Catholic hospitals and staff, I have seen the tremendous influence of the Catholic Health Association which boasts that it’s health care ministry comprises more than 600 hospitals and 1,600 long-term care and other health facilities in all 50 states,  When I received my nursing education in a Catholic hospital in the late 1960s, rigorous ethics were an important part of our nursing education with “do no harm” to patients, report our mistakes, never lie, advocate for our patients regardless of age, socioeconomic status or condition, etc. incorporated as standard requirements. We happily took the Nightingale Pledge as our standard of excellence.

But now, as Catholic Health Association ethicists Fr. Patrick Norris and the late Fr. Kevin O’Rourke have stated in 2007 regarding futility :

“end-of-life decisions exemplify the principle of double effect, (wh)erein the withholding/withdrawing of life support is either morally good or neutral, the intention of the act being to remove either an ineffective or gravely burdensome treatment. The evil effect of the death is not a means to achieving the good effect (avoiding an inappropriate treatment), and, given appropriate circumstances, the good achieved is commensurate with the harm that occurs as a foreseen but unintended effect of a good action. The invocation of the principle of double effect in these cases properly distinguishes between physical causality and moral culpability.” (Emphasis added)

CONCLUSION

I have been called by many distraught relatives who have said they thought their loved one was “safe” in a Catholic hospital but saw problems. One case involved an older woman who had a stroke (cerebral vascular accident) and was in a coma and expected to imminently die but continued to live several days later with normal vital signs. The woman had a pro-life living will to reject life-sustaining treatment, including a feeding tube, if she had a “terminal event” and was imminently dying. The relative wanted to know if this was indeed a “terminal event”.

I asked if the woman was on a morphine infusion. She was and hadn’t seemed to be in pain. I explained that the sedation could account for her coma and suggested that they ask the doctor about trying to slow or stop the morphine to see.

The relative called back to say that the morphine was stopped and that the woman started to wake up and even seemed to recognize them. However, the Catholic chaplain told the woman’s sister who was her power of attorney for health care that her apparent response was only a reflex. The sister ordered the morphine turned back on.

The family was upset and considered legal action but decided that this would split the family so they gave up. Not surprisingly, the woman eventually died 2 weeks later.

After this case, I later wrote a blog “Living with ‘Living Wills’ about the little-known pitfalls of advance directives and how they could work against what a person wants.

The bottom line is that everyone must remain vigilant when they or a loved one becomes seriously ill, regardless of the hospital or institution. It is also important not to be afraid to ask questions.

There are also non-denominational, non-profit groups like Hospice Patients Alliance  and the Healthcare Advocacy and Leadership Organization (I am on the advisory board) that have much useful information and resources for patients, families and the public.

But without a change in policies and attitudes, those of us medical professionals who believe we should never cause or hasten death may become an endangered species as well as our medically vulnerable patients.

Roe v Wade 47 Years Later

Like everyone else I knew, no one expected the US Supreme Court’s case Roe v Wade to legalize abortion in 1973. I was shocked when the Court legalized abortion with virtually no restrictions during the first trimester stating:

“(a) For the stage prior to approximately the end of the first trimester, the abortion decision and its effectuation must be left to the medical judgment of the pregnant woman’s attending physician. Pp. 163, 164.
(b) For the stage subsequent to approximately the end of the first trimester, the State, in promoting its interest in the health of the mother, may, if it chooses, regulate the abortion procedure in ways that are reasonably related to maternal health. Pp. 163, 164.” (Emphasis added)

It wasn’t until much later that I learned about the Doe v Bolton case (decided at the same time as Roe) that expanded the definition of “health”, stating that the “medical judgment (for abortion) may be exercised in the light of all factors–physical, emotional, psychological, familial, and the woman’s age–relevant to the well-being of the patient. All these factors may relate to health.” (Emphasis added)

That redefinition of a woman’s health opened the expansion of abortion.

Unfortunately, those of us who expressed horror about these decisions were quickly derided by those who supported legalized abortion. Even those of us who were medical professionals and knew better felt intimidated.

MY PERSONAL EXPERIENCE WITH ABORTION AND ITS EFFECTS

When I became a mother a few years after the Roe v Wade decision and read the prenatal development pamphlet given to expectant mothers, my heart ached for those mothers who chose abortion without such crucial information.

Eventually, I had a daughter born with Down Syndrome and a severe heart defect as well as another daughter who became pregnant at 18. I could understand the fear and desperation underlying an abortion decision and I was determined to help in some way by joining the pro-life movement.

Because of the pro-life movement, I have been better able to help desperate mothers, children with disabilities and their families as well as other people in danger of being seen as “inconvenient”, “unwanted” or “better off dead”.

THE ABORTION TRAJECTORY AND HOW IT IS CHANGING

After the Roe decision, it didn’t take long before “abortion rights” to begin expanding and now we have at least 8 states legislating abortion on demand throughout pregnancy  as well as at least 19 states allowing abortionists to leave babies to die who survive abortion.

Most recently, pro-abortion Democrats have blocked efforts to get Congress to vote on the “Born-Alive Abortion Survivors Protection Act” and in my home state of Missouri, the last Planned Parenthood clinic is still fighting closure over its health violations.

But despite all this activity on the pro-abortion side, many states have enacted strong protections for mothers and their unborn babies. Even the pro-abortion Guttmacher Institute acknowledges that:

“In 2019, conservative state legislators raced to enact an unprecedented wave of bans on all, most or some abortions, and by the end of the year, 25 new abortion bans had been signed into law”

And an encouraging new Marist/Knights of Columbus poll  shows that a majority of Americans (65%) would vote for candidates who back abortion restrictions and nearly two-thirds of Americans oppose abortion if the child will be born with Down Syndrome.

In addition, there are more pregnancy help centers than abortion clinics to help women and their unborn babies.

CONCLUSION

As abortions are decreasing and the abortion movement is exposed for its radical goals, it appears that more and more people are seeing the truth about abortion and the pro-life movement. Personally, I have never felt more encouraged since the Roe v Wade decision 47 years ago and especially by the inspiring words of President Donald Trump, the first sitting president to address the annual March For Life in Washington, D.C.:

“We cannot know what our citizens yet unborn will achieve. The dreams they will imagine. The masterpieces they will create. The discoveries they will make. But we know this: every life brings love into this world. Every child brings joy to a family. Every person is worth protecting….

Together, we will defend this truth all across our magnificent land. We will set free the dreams of our people. And with determined hope, we look forward to all of the blessings that will come from the beauty, talent, purpose, nobility, and grace of every American child.”

Lethal Problems with Medical Futility and Disability Bias

In 2018,  Chris Dunn survived a freak diving accident that left him paralyzed, mostly blind and on a ventilator to breathe.  He spent most of the next year in an ICU in rural Maine.

Unable to see, eat, breathe or move on his own, the 44 year old father and concrete work spent his days in bed listening to the History Channel and hoping for a chance to show he could do more.

Efforts to find a rehab center failed. Even worse, hospital administrators and others were encouraging Chris’s mother Carol to put him in hospice to die.  As the article states:

“Drugged up and confined to bed, Chris waited while dealing with a hospital staff that didn’t know what to do with him. ‘There would be nurses that would come in and tell me, ‘You know you’re making your son suffer,’ says Carol. ‘I mean, what’s a mother to do with that?’”  (Emphasis added)

However, Carol refused to give up trying to find help for Chris and after 7 months, finally contacted the United Spinal Association. Jane Wierbicky, a longtime nurse and a member of the Association’s Resource Center team worked to help find a rehab center in Atlanta.

Now Chris only uses the ventilator a few hours a night, got outdoors to catch a fish, and returned home to spend Thanksgiving with his mother and girlfriend.

With the help of his mother and a team of advocates, Chris hopes to eventually live in an accessible apartment.

Medical care for Chris was not futile.

MEDICAL FUTILITY

The National Council on Disability defines “medical futility” as

“an ethically, medically, and legally divisive concept concerning whether and when a healthcare provider has the authority to refuse to provide medical care that they deem ‘futile’ or ‘nonbeneficial’. A “medical futility decision” is a decision to withhold or withdraw medical care deemed “futile” or “nonbeneficial.” (Emphasis added)

Because of my professional and personal experiences with disability bias as well as my volunteer work with people with disabilities, I have seen firsthand the potentially lethal effects of medical futility decisions based on disability. I have been writing on this topic for years, most recently on Missouri’s Simon’s Law enacted after the parents of a baby with Trisomy 18 and a heart defect who died later found out that doctors had ordered a “Do Not Resuscitate” and withheld life-sustaining treatment without their knowledge due to a secret medical futility policy at the Catholic hospital treating their son.

Recently, I found out that the National Council on Disability just published a 82 page comprehensive report titled “Medical Futility and Disability “  as part of a five-report series on the intersection of disability and bioethics.

In a letter to President Trump, the Council chairman states that the series:

“focuses on how the historical and continued devaluation of the lives of people with disabilities by the medical community, legislators, researchers, and even health economists, perpetuates unequal access to medical care, including life-saving care.

and notes that:

“In recent years, there has been a push to regulate medical futility decisions on the state and institutional levels. State laws, which vary greatly in their content and approach, define the protections, or lack thereof, of a patient’s wishes to receive life-sustaining treatment. Hospitals have turned to process based approaches, utilizing internal ethics committees to arbitrate medical futility disputes. Despite the increased attention, however, disability bias still finds its way into futility decision making.” (All emphasis added)

The Council identifies four factors that are influencing the futility debate today: “Advanced life-saving medical technology, Changes in healthcare reimbursement, Evolving concepts of patient autonomy and the Rise of the right-to-die movement”.

The report also extensively explores the legal issues  and several court decisions involving medical futility like the Terri Schiavo and Haleigh Poutre cases.

STATE LAWS

The Council report also evaluated current state laws regarding medical futility decisions and found only 11 with strong patient protections, 19 without patient protections, 19 with weak patient protections, and 2 with time-limited patient protections.

Further complicating the state laws is the lack of transparency for patients or other family members regarding an institution’s medical futility policies. Hospitals are rarely transparent with their medical futility policies, as in the Simon’s Law case. The report is right when it states that “the disclosure of medical futility policies is essential to providing patients, their surrogates, and their families with the information they need to protect their rights and ensure accountability”.

The Council also notes that “Disability nondiscrimination laws, including the ADA and Section 504 of the Rehabilitation Act, provide a viable, yet largely unexplored vehicle for enforcing the rights of people with disabilities in the medical futility context.”

The report ends with recommendations for Congress, the executive branch, medical and health professional schools, professional accreditation bodies, healthcare insurers and state legislatures to combat the problem of disability bias in healthcare.

CONCLUSION

One of the reasons I chose to become a nurse decades ago was the strong ethical principles in medicine. We were educated to treat all patients to the best of our ability regardless of race, disability, socioeconomic status, etc.  “Quality of life” was something to improve, not judge. The traditional hospice philosophy was to neither hasten nor prolong dying.

But over time, I saw ethics change. As the report itself notes, the advances in technology, changes in health care reimbursement, evolving concepts of patient autonomy and the rise of the right-to-die movement led to radical changes in both law and medical ethics.

The concept of medical futility was no longer limited to medically certain circumstances of treatment ineffectiveness but, all too often, also to the patient’s (and sometimes the family’s) perceived “quality of life”.

Such disability bias is often unrecognized, even by the medical professionals caring for the person, but it is a real bias that must be eliminated in our society.

I admire people like Chris Dunn and his determined mother who show us the possibilities when people with even severe disabilities get a chance to have the best life possible.

 

 

 

 

 

 

 

 

Are We Witnessing the Coming Extinction of Conscience Rights?

Last month, Wesley Smith, the well-known writer and lawyer who opposes assisted suicide and abortion, wrote an article titled “Bioethicist Wants to Morally Cleanse Medical Schools”  about plans to weed out pro-life potential doctors and nurses from even entering medical and nursing schools:

“Make no mistake. Schuklenk and his ilk — such as the adamant opponent of medical conscience, Ezekiel Emanuel — are deadly serious about crushing all dissent within the medical professions to emerging cultural paradigms, and plan to morally cleanse the ranks of doctors, nurses, pharmacists, and institutions of all  wrong thinkers, particularly of the religious and pro-life kind.”

As Wesley warns after speaking with such prospective medical and nursing students, “such culling already occurs outside of official policy”.

CONSCIENCE RIGHTS FOR HEALTH CARE INSTITUTIONS

Now health care institutions that forbid their employees from participating in abortion and euthanasia are at risk.

As an October 29, 2019 article in the Journal of the American Medical Association (JAMA) titled “Colorado End-of-Life Options Act-A Clash of Organizational and Individual Conscience” explains, a new court case may result in conscience rights being legally upheld when a doctor agrees to help a patient commit assisted suicide against a religious healthcare institution’s policy.

This came about when the Colorado legislature could not pass a physician-assisted suicide in 2014 and 2015 but a new, problematic referendum was introduced and passed by Colorado voters in 2016.

While hospitals and clinics in other states with assisted suicide laws are allowed to prohibit their employees from participating, the Colorado, the referendum added a little-noticed provision in the 2016 Colorado referendum that stated:

“A health care facility may prohibit a physician employed or under contract with the facility from prescribing medication to an individual who intends to use the medication on the facility’s premises. The facility must provide advance written notice of its policy to the physician and its patients. A health care facility may not discipline a physician, nurse, pharmacist, or other person for actions taken in good faith or for refusing to participate in any way.” (Emphasis added)

As the JAMA article notes,This provision virtually guaranteed the Colorado law would eventually be challenged”.

This set up the current case Mahoney et al v. Centura Health Corporation” involving Neil Mahoney, a Colorado man with advanced cancer, who wanted physician-assisted suicide and found geriatrician Barbara Morris, MD. Dr. Morris was willing to write the lethal overdose prescription. However, the religiously based Centura Health System where she was employed forbade participation in assisted suicide. Mr. Mahoney and Dr. Morris filed a lawsuit on August 21, 2019 and the doctor was fired on August 26 for violating the ethical directives provided for Catholic health care services.

The article concludes that:

“the case seems destined to have a potentially significant effect on national policy. If the courts rule that the Constitution allows hospitals to exert control over individual physicians’ claims of professional conscience, it will be a victory for corporate medicine.

But if the state law is upheld, the case could establish that physicians’ professional conscience claims hold or take precedence over the ethical and religious directives of religiously affiliated hospitals. It is possible that at least some religiously affiliated health systems might rather close than allow that outcome.” (All emphasis added)

CONCLUSION

As Wesley Smith writes, eliminating pro-life health care providers and institutions is  becoming part of an utilitarian agenda in the bioethics movement where “legalized euthanasia, free and unfettered abortion at all stages of gestation, infanticide, eugenic embryo engineering, invidious forms of health-care rationing based on ‘quality of life,’ etc., are all part of the mainstream bioethics agenda, or at the very least, are seen as respectable advocacy memes.”

With the current support of a predominantly sympathetic mainstream media, well-funded and politically active groups like Planned Parenthood and Compassion&Choices are also putting pro-life health care providers and their supportive institutions in grave danger of becoming an endangered species in law, politics and health care.

If this happens, our health care system will radically change-especially for the unborn, the elderly and people with disabilities.

When dedicated and compassionate people are denied entry into the health care professions because they refuse to deliberately end lives, harassed and/or fired when they refuse to participate in a deliberate death decisions and religiously based healthcare institutions are forced by law to allow lives to be ended by “choice” or close their doors, will any of us be able to trust our healthcare system when we need it the most?

We need to educate ourselves and the public before it’s too late.