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Bioethics Report on Care for Chronically Ill and Elderly Patients AND Death and Dying

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Manuel Yoro

on 13 February 2013

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Transcript of Bioethics Report on Care for Chronically Ill and Elderly Patients AND Death and Dying

Finally Care for the Elderly and Chronically Ill Care for the Chronically Ill and Elderly Care for the Elderly and Chronically Ill Ordinary and Extraordinary Forms of Treatment Principles of Geriatric Care Death and Dying Determination of Death Yu, Bryan N. is the accumulation of changes in a person over time.

multidimensional process of physical, psychological and social change.

Ageing is an important part of all human societies reflecting the biological changes that occur, but also reflecting cultural and societal conventions.

Roughly 100,000 people worldwide die each day of age-related causes. Aging Yu, Bryan N. or simply eldercare
is the fulfillment of the special needs and requirements that are unique to senior citizens
This broad term encompasses such services as
assisted living,
adult day care,
long term care,
nursing homes,
hospice care,
and home care. Elderly Care Yu, Bryan N. which states that,

“All human beings are born free and equal in dignity and rights” Universal declaration of human rights (1948) Yu, Bryan N. Health care is a basic right, but it is often regarded as an expensive luxury.
Despite passage a decade ago of Medicare, millions of elderly people still lack adequate medical care. The Right to Health Care Yu, Bryan N. Elderly are the most severely malnourished group in society.
Poor nutrition is a major factor in the incidence of poor health among them. Right to Eat Yu, Bryan N. The elderly do not forfeit their claim to basic human rights because they are old…
“Every man has the right to life, to bodily integrity, and to the means which are suitable for the proper development for life; these are primarily food, clothing, shelter, rest, medical care, and finally the necessary social services. Therefore, a human being also has the right to security in cases of sickness, inability to work, widowhood, old age, unemployment, or in any other case in which he is deprived of the means of subsistence through no fault of his own” (Pope John XXIII, Peace on Earth) Human Rights and the Elderly Yu, Bryan N. Elderly care emphasizes…
the social and personal requirements of senior citizens who need some assistance with daily activities and health care, but who desire to age with dignity.
It is an important distinction, in that the design of housing, services, activities, employee training and such should be truly customer-centered. Yu, Bryan N.
The average longevity span of the
Filipino female – 72.8 years
Filipino male – 67.5 years Yu, Bryan N. Taking care of an elderly family member at home requires genuine attention, patience, dedication, time and effort. 
Caring for an elderly is a good way to return the love and kindness to someone who has taken great care of you through the years. 
Some elderly individuals require more assistance than others. 
There are some who need round the clock help. 
Looking after an aging individual is not easy and has its share of challenges along the way. Yu, Bryan N. Longer life expectancy
Diminished reserve
Easily disrupted homeostasis
Depression is common
Multiple chronic diseases
Multiple cause for malnutrition
Multiple cause for functional disability
Multiple causes for pain and discomfort
Polypharmacy Facts about older people Yu, Bryan N. Illness tends to affect older people in the following atypical ways:

Functional decline
Decrease or cessation of eating/drinking
Falling or gait disorder
Urinary incontinence
Dizziness
Mental confusion
Weight loss
Depression and withdrawal Yu, Bryan N.
Memory or cognitive loss
Vision loss
Hearing loss
Educational level
Ageism
Motivation
Conflicts between patient and care giver Barriers to communication in the elderly: Yu, Bryan N. *Hearing loss and Vision loss can lead to withdrawal, increased morbidity and mortality DEPRESSION
Is common and frequently under diagnosed POLYPHARMACY
is very prevalent in the elderly as the number of diseases esp. chronic ones increases as age increases AGEISM
the attitude that disease and disability are inevitable part of aging and can lead to delayed diagnosis and treatment and misses opportunities to develop full life potentials Yu, Bryan N. Common syndromes of elderly persons:
- acute delirium
- dementia
- falls / gait problem
- urinary incontinence
- constipation
- malnutrition
- depression
- polypharmacy
- frailty
- sensory loss Yu, Bryan N. Pressure sores
Osteoarthritis
Sleep problems
Cancer
Loss of vision & hearing
Infection Coronary heart diseases
Hypertension
Osteoporosis & fractures
Diabetes mellitus
Alzheimer’s disease
Parkinson’s disease Common Diseases/Disorders Yu, Bryan N. Includes Functional tests:
Physical exam
Mini-Mental State exam
Status exam
Depression scale
Psycho-social exam
Economic and Environmental Domains Comprehensive Geriatric Assessment (GSA) Yu, Bryan N.
Mission of Geriatric Medicine:
Identify, stabilize and delay the progression of chronic medical conditions and prevent acute and iatrogenic conditions

*** Physicians caring for the frail elderly should recognize the importance of focusing on the following as goals of geriatric care:
Functional abilities
Quality of life
Comfort
Safety
Happiness Yu, Bryan N. Set a family meeting
Communicate with the elderly
Establish a safe environment
Beware of medical condition
Spend quality time with the elderly
Be more patient and understanding
Give room for independence Tips on Elderly Care Chronically Ill Yu, Bryan N. A chronic condition is a
Human health condition/disease that is persistent in its effects
The course of the disease lasts for more than 3mos

A debilitating condition that interfere with an individual's way of living a normal life and dealing with the society brought about by different signs and symptoms lasting from 6 months and above. Yu, Bryan N. Common Chronic Diseases
Arthritis
Asthma
Cancer
COPD
Diabetes
HIV/AIDS Yu, Bryan N. Some people with chronic health problems are not disabled
Continuing medical treatment can mitigate dysfunction so the person encounters no extraordinary difficulties in executing major life activities
Eg: multiple sclerosis, diabetes, glaucoma, HIV infection, and sickle cell disease Chronic illness Yu, Bryan N. In most chronic illnesses and long term care situations, the health of the whole family is intrinsically connected to the patient’s well-being that every ethical considerations must consider the long term course of decisions and how it will affect the family. Yu, Bryan N. GOAL:
Care not cure,
Comfort,
Function
Independence PRINCIPLES OF GERIATRIC CARE Yu, Bryan N. Care Givers etc comprehensive multidisciplinary assessment is essential
look for undiagnosed diseases, it is almost always present
beware of non-specific presentation of illness
depression is the great masquerader in geriatrics
do not underestimate the morbid contributions of hearing and vision loss Doctors Tasks of the Medical Team Ethics Principles Ethical Principles Ethical Principles Death and Dying Death and Dying Death and Dying Yara, Roanne Jemae H. “Resolve to be tender with the young, compassionate with the aged, sympathetic with the striving, and tolerant with the weak and the wrong. Sometime in your life you will have been all of these.”


 Dr Robert H Goddard Yara, Roanne Jemae H. “Caring for our seniors is perhaps the greatest responsibility we have. Those who walked before us have given so much and made possible the life we all enjoy.” Yara, Roanne Jemae H. The phrase sanctity of life refers to the idea that human life is sacred
Genesis 1:27   So God created man in his own image, in the image of God he created him; male and female he created them.
Psalm 139:13-16   For you created my inmost being; you knit me together in my mother's womb. I praise you because I am fearfully and wonderfully made; your works are wonderful, I know that full well. My frame was not hidden from you when I was made in the secret place. When I was woven together in the depths of the earth, your eyes saw my unformed body. SANCTITY OF LIFE Yara, Roanne Jemae H. "Every person, from the moment of conception to natural death, has inherent dignity and a right to life consistent with that dignity."[3]
Human life at every stage of development and decline is precious and therefore worthy of protection and respect. It is always wrong directly to attack innocent human life.
The Catholic tradition sees the sacredness of human life as part of any moral vision for a just and good society. RESPECT FOR HUMAN LIFE Yara, Roanne Jemae H. God created us in his image and likeness
Every person regardless of race, sex, age, national origin, religion, sexual orientation, employment or economic status, health, intelligence, achievement or any other differentiating characteristic is worthy of respect. It is not what you do or what you have that gives you a claim on respect; it is simply being human that establishes your dignity. Given that dignity, the human person is, in the Catholic view, never a means, always an end. HUMAN DIGNITY Yara, Roanne Jemae H. Beneficence involves balancing the benefits of treatment against the risks and costs involved
Beneficence is action that is done for the benefit of others. BENEFICENCE Yara, Roanne Jemae H. non-maleficence means avoiding the causation of harm NON MALEFICENCE Yara, Roanne Jemae H. In general, justice refers to what is owed or due to the individual members of society. JUSTICE Yara, Roanne Jemae H. Respecting the choices and wishes of persons who have the capacity to decide and protecting those who lack this capacity.
Right to choose or refuse treatment. AUTONOMY Yara, Roanne Jemae H. What God has created should be treated with respect and reverence.
We are called to exercise responsible stewardship which protects the integrity of God’s Creation. This is essential for the well-being of people. STEWARDSHIP Ethical Principles Yara, Roanne Jemae H. The intrinsic worth that inheres in every human being. From the Catholic perspective (among other Christian perspectives), the source of human dignity is rooted in Christ’s redemption and in our ultimate destiny of union with God.
Human dignity therefore transcends any social order as the basis for rights and is neither granted by society nor can it be legitimately violated by society. In this way, human dignity is the conceptual basis for human rights. HUMAN DIGNITY Yara, Roanne Jemae H. As a gift from God, every human life is sacred from conception to natural death. The life and dignity of every person must be respected and protected at every stage and in every condition. The right to life is the first and most fundamental principle of human rights that leads Catholics to actively work for a world of greater respect for human life and greater commitment to justice and peace. RESPECT FOR HUMAN LIFE Yara, Roanne Jemae H. The principle of beneficence guides the ethical theory to do what is good.
This principle stipulates that ethical theories should strive to achieve the greatest amount of good because people benefit from the most good. BENEFICENCE Yara, Roanne Jemae H. “above all do no harm”
Requires that risks, discomforts, and harms inherent in medical or surgical treatment be offset by proportionate therapeutic gains for the patient. NON MALEFICENCE Yara, Roanne Jemae H. Requires appreciation of the two gifts God has given us: the earth with its natural resources, and our own human nature.

We are not the owners of our lives and, hence, do not have absolute power over life. We have a duty to preserve our life and to use for the glory of God. STEWARDSHIP Yara, Roanne Jemae H. doctors who are guardians and servants of human life can become manipulators of life, or even agents of death.

both reason and faith require that we resist every temptation to end a patient's life by a deliberate act of omission or by active intervention because euthanasia is a grave violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person POPE JOHN PAUL II Yara, Roanne Jemae H. In the current climate of increasing desire for a dignified death, if a better job were done of honoring patients’ wishes to forgo expensive life-prolonging intervention, then both justice and autonomy would be served JUSTICE Yara, Roanne Jemae H. root of decisions by patients to forgo life-sustaining treatment at the end of life
The patient is the one to decide about forgoing life-sustaining interventions
Respecting the choices and wishes of persons who have the capacity to decide and protecting those who lack this capacity.
Right to choose or refuse treatment. AUTONOMY Yara, Roanne Jemae H. This right and responsibility is exercised by freely and voluntarily consenting or refusing consent to recommended medical procedures, based on a sufficient knowledge of the benefits, burdens, and risks involved.
Patients (parents if the patient is a child) deserve a clear, complete understanding of all therapies that are being proposed for them. INFORMED CONSENT Yoro, Manuel D. “Death is part of a narrative or story of life of every human being, a mortal being.”

- cf Eccl 3:2 Yoro, Manuel D. Cultural and Religious Influences
Rebirth and reincarnation
From mundane world to that of the departed
Social Influences
Leveler and validator
Developmental Influences
Erik Erikson’s Psychosocial Stages Perceptions of Death Yoro, Manuel D. ? or Defining Death... Process Event Yoro, Manuel D. As a PROCESS,
Degenerative and destructive changes associated with aging
It starts when the person is still living
Confuses the process of death with the process of dying
Someone who is dying is not yet dead
Process of death starts when the person is no longer alive
Confuses process of death with the process of disintegration (condition of being decayed) Defining Death... Yoro, Manuel D. It should be viewed not as a process but as the event that separates the process of dying from the process of disintegration Defining Death... Yoro, Manuel D. Permanent cessation of functioning of the organism as a whole (the highly complex interaction of its organ subsystems or of the entire brain)

It is not necessary that all subsystems be integrated.
Individual subsystems may be replaced (e.g. pacemakers, ventilators, or pressors) without changing the status of the organism as a whole. Defining Death... Yoro, Manuel D. 2 competing criteria of death:
Permanent loss of cardiopulmonary functioning
Total and irreversible loss of whole brain functioning DEATH Yoro, Manuel D. 1. the body no longer exhibits specific human behavior
2. it will not be able to function humanly in the future
3. it no longer has a radical capacity for human functions because it has lost the basic structures required for human unity
Due to possible recovery from a coma-state Death is certain if: Yoro, Manuel D. Permanent loss of cardiopulmonary functioning
Used since ancient times

Case:
Consider a conscious talking patient who is unable to breath because of suffering from poliomyelitis and who requires an iron lung (thus, having permanent loss of spontaneous pulmonary function), who has also developed asystole (loss of spontaneous heartbeat) requiring a permanent pacemaker (thus having permanent loss of spontaneous cardiac function) CRITERION OF DEATH Yoro, Manuel D. Proposed criterion:
Permanent loss of all cardiopulmonary function, whether spontaneous or artificially supported

Case:
An organism with permanent loss of whole brain functioning can have permanently ceased to function as a whole days to weeks before the heart and lungs ceased to function with artificial support. CRITERION OF DEATH Yoro, Manuel D. Continued artificially supported cardiopulmonary function is no longer perfectly correlated with life.

Permanent loss of spontaneous cardiopulmonary function is no longer correlated with death. CRITERION OF DEATH Criterion of Death Yoro, Manuel D. Patient on a ventilator with a totally destroyed brain is merely a preparation on artificially maintained subsystems since the organism as a whole has ceased to function.

Consistent with tradition:
Unresponsivity
lack of spontaneous movements including breathing
Absence of pupillary light response
Unresponsivity (deep coma)
Abset pupillary light reflexes
Apnea
Absent brainstem reflexes
Absence of drug intoxication and low body temperature
Brain lesions
Isoelectric (flat) EEGs
Tests disclosing the absence of blood flow CRITERION OF DEATH Yoro, Manuel D. Ceasing respiration
Pallor mortis, paleness which happens almost instantaneously (in the 15–120 minutes after the death)
Livor mortis, a settling of the blood in the lower (dependent) portion of the body
Algor mortis, the reduction in body temperature following death. This is generally a steady decline until matching ambient temperature
Rigor mortis, the limbs of the corpse become stiff (Latin rigor) and difficult to move or manipulate
Decomposition, the reduction into simpler forms of matter SIGNS OF DEATH Yoro, Manuel D. Unreceptivity and unresponsitivity--patient shows total unawareness to external stimuli and unresponsiveness to painful stimuli;
No movements or breathing--all spontaneous muscular movement, spontaneous respiration and response to stimuli are absent;
No reflexes--fixed, dilated pupils; lack of eye movement even when hit or turned, or ice water is placed in the ear; lack of response to noxious stimuli; unelicitable tendon reflexes.
Flat EEG is recommended
Drug intoxication & hypothermia ruled out as the cause
Persistent vegetative state vs. brain death HARVARD Criteria for Brain Death (1968) Yoro, Manuel D. Total brain death = sufficient criterion for human death
Partial brain death = not sufficient death
We do not believe that death should be certified as long as patients are able to maintain spontaneous breathing and a heartbeat because this constitutes strong evidence that the brain is the seat of radical unity of the human body is still living even if there is no evidence of its higher functions. Although there may be reasonable doubts, the benefit of the doubt should be given to the person in question. Brain Death Yoro, Manuel D. Total Brain Death
Irreversible cessation of all the functions of the entire brain, including the brainstem

Neocortical Brain Death
Persistent Vegetative State
Cerebral hemispheres are damaged extensively and permanently
Brainstem is relatively intact Brain Death Yoro, Manuel D. Receiving increasing attention in our society.

Some of the reasons include:

Scientific progress that has led to the cure of diseases that formerly resulted in death.
The ability of medicine to develop new technologies to supplement the body and organ systems which are necessary to sustain life (heart bypass, dialysis, transplantation).
New technologies (Internet) that provide ready access to worldwide and the latest scientific data regarding specific diseases.
Better nutrition, preventive health care and knowledge regarding good health habits that have increased longevity and decreased mortality rates. Death and Dying Yoro, Manuel D. Ashley, B. M., & O’Rourke, K. D. (2002). Ethics of health care. 3rd ed. Washington, DC: Georgetown University Press.

Backer, B. A., Hannon, N. R., & Russell, N. A. (1994). Death & dying: Understanding and Care. 2nd ed. Albany, NY: Delmar Publishers, Inc. References Julia Angeli P. Young Ordinary Forms of Treatment Young, Julia Angeli P. April 1975, a 21-year old female ingested an undetermined amount of alcohol and tranquilizers
Persistent Vegetative State
Sustained by a ventilator and feeding tubes for 7 months
Physicians concluded that there was no hope for recovery Case: Karen Ann Quinlan Young, Julia Angeli P. Parental Wishes vs. Physician Wishes
Parents: felt that it’s against God’s will to keep their daughter in such state and that their daughter wouldn’t have wanted to live that way.
Physicians: patient did not match the criteria for brain death
New Jersey Supreme Court decision:
“…when an individual has no chance of recovering a cognitive sapient state the argument for the protection of life weakens and the individual’s right to privacy may call for discontinuance of burdensome life support as determined by guardian.” Case: Karen Ann Quinlan Young, Julia Angeli P. Weaned off ventilator
Maintained on tube feedings, IV fluids
Died 10 years after Case: Karen Ann Quinlan Young, Julia Angeli P.
What is the distinction between morally acceptable treatments?
Suicide?
Dignified death? Young, Julia Angeli P. McCabe, M. ORDINARY MEANS – EXTRAORDINARY MEANS: A VALID DISTINCTION?. The New Zealand Catholic Bioethics Centre Ordinary Means
Physicians: standard; prolong life (physiologic function)
Ethicists: prolong life according to what is morally obliged of us to preserve life or health

We take into consideration both the resources and the patient reference. Definition Young, Julia Angeli P. Richard Benson, CM, PhD, STD.(2010) Ordinary/Extraordinary Means A Significant Moral Distinction.
California Catholic Conference. http://www.embracingourdying.com/theological/oemeans.php “Ordinary means are all medicines, treatments, and operations that offer a reasonable hope of benefit and which can be obtained without excessive expense, pain, or other inconvenience.”
Gerald Kelly S.J. Definition Young, Julia Angeli P. Pope Pius XII, “Address of Reanimation” Acta Apostolicae Sedis 49 (1957) 1027-1033.
1957 Encyclical “Prolongation of Life” by Pope Pius XII
“one was held to use only ordinary means—according to circumstances of persons, places, times, and culture—that is to say, means that do not involve any grave burden to oneself or another.” Definition Young, Julia Angeli P. Edge, R, Groves, J. Ethics of Health Care: A Guide for Clinical Practice 3rd ed. Thomson, NY, 2005. There is due proportion between the means used and the end intended
Proportionate: good chance of success, easily available, acceptable to patient
Disproportionate: futile, excessively burdensome, morally unacceptable Proportionate and Disproportionate Charmagne Loren L. Yerro Extraordinary Forms
of Treatment Charmagne Loren L. Yerro

by: Dr. Michael Asciak MD, M.Phil. Doctors mistakenly tend to use the terms as referring to „standard‟ or
„non-standard‟ forms of treatment. judgment about how a treatment will affect the quality of life for a patient
element of the distinction, there is the question of a norm for the element.
prudence, … within Roman Catholic traditional teaching … judges not only according to rational self-interest but according to the promptings of the Holy Spirit. Before analyzing, one must have: http://www.ts.mu.edu/readers/content/pdf/57/57.3/57.3.6.pdf What emerged in Roman Catholic traditional teaching was an understanding of human life in which there is considerable, though limited, freedom given to human beings.

One such limitation is that WE DO NOT POSSESS TOTAL DISPOSITION OVER OUR OWN LIFE.
We are obliged to conserve human life. This obligation forbids any person to take his or her own life.

The more difficult dimension of the obligation, however, is to determine the positive duty one has to conserve life. What is the nature and extent of one's duty to conserve life?

This question has particular importance in health care in determining the extent to which a person must seek treatment for disease or illness. In articulating one's obligation to seek treatment, traditional teaching sets out a distinction framed in terms of an understanding of one's earthly life and ultimate end.

Life is understood as a gift in relationship to personal salvation and eternal happiness. So traditional teaching has argued for an obligation to conserve life that is balanced by other obligations and by the view that love of God orders all obligations. Richard Benson, CM, PhD, STD.(2010) Ordinary/Extraordinary Means A Significant Moral Distinction. California Catholic Conference. http://www.embracingourdying.com/theological/oemeans.php McCabe, M. ORDINARY MEANS – EXTRAORDINARY MEANS: A VALID DISTINCTION?. The New Zealand Catholic Bioethics Centre - all medicines, treatments, and operations, which cannot be obtained or used without excessive expense, pain or other inconvenience, or which if used, would not offer a reasonable hope of benefit. - medicines, treatments, and operations, which offer a reasonable hope of benefit and which can be obtained and used without excessive expense, pain, or other inconvenience. - means or measures which are NOT in this way morally required - prolonging life which are MORALLY REQUIRED in view of the duty (of the doctor and/or patient) to preserve life and health. Extraordinary Ordinary VS Ordinary‟ and extraordinary means of prolonging life‟, The Linacre Centre for Healthcare Ethics, extract from Life and Death in Healthcare Ethics, Routledge, 2000. http://www.lifeissues.net/writers/mis/mis_01prolonginglife.html In the view of ethicist: Charmagne Loren L. Yerro - means or measures which are not usually available, do not offer a reasonable hope of benefit and cause unbearable pain and suffering Ordinary & Extraordinary – Hydration & Nutrition
by Dr. Michael Asciak MD, M.Phil. Theological Studies 57 (1996)
ORDINARY AND EXTRAORDINARY MEANS AND THE QUALITY OF LIFE
KEVIN W. WILDES, S.J. (Georgetown University)
http://www.ts.mu.edu/readers/content/pdf/57/57.3/57.3.6.pdf - means of prolonging life which are available, offer a reasonable hope of benefit and do not cause unbearable pain and suffering. - a person may be able physically to utilize means for preserving life but still be incapable of using the available means because of fear, danger, or inconvenience. Such conditions create a moral impossibility… hence NOT OBLIGATORY. - means that DO NOT create moral or physical impossibilities Extraordinary Ordinary VS In the view of ethicist: Charmagne Loren L. Yerro Even in the absence of special commitments, however, there is no obligation for a patient to take measures to promote life and health if these measures will involve excessive burdens. Charmagne Loren L. Yerro .. ”if the burdens outweigh the benefits or it offers no hope of benefit for the patient.” High Risk
Complex, relatively high tech.
Innovative, experimental, unusual.
Relatively small chance for benefit to the patient.
Relatively expensive.
Available to few (may involve distributive justice issues).
Usually a source of pain or distress. Purtilo, R. Ethical Dimensions in the Health Professions (Saunders, 1999) p220. http://www.pages.drexel.edu/~cp28/ordextr.htm Charmagne Loren L. Yerro Extraordinary Forms of Treatment if: Theological Studies 57 (1996)
ORDINARY AND EXTRAORDINARY MEANS AND THE QUALITY OF LIFE
KEVIN W. WILDES, S.J. (Georgetown University)
http://www.ts.mu.edu/readers/content/pdf/57/57.3/57.3.6.pdf Charmagne Loren L. Yerro Extraordinary means are those that would constitute a moral impossibility for human beings in general (absolute norm) or for a particular person (relative norm).

Cronin’s FIVE General Headings:

An impossibility factor {quaedam impossibilitas) exists in cases where it is impossible either to obtain the means or to use them even if attainable. The essential element of an extraordinary means is that it presents a moral impossibility.

Roman Catholic moralists have also relied on the notion that an effort might be too difficult (summus labor and nimis dura) in order to allow for a means that would require excessive effort. Theological Studies 57 (1996)
ORDINARY AND EXTRAORDINARY MEANS AND THE QUALITY OF LIFE by KEVIN W. WILDES, S.J. (Georgetown University)
http://www.ts.mu.edu/readers/content/pdf/57/57.3/57.3.6.pdf Charmagne Loren L. Yerro
Cronin’s FIVE General Headings:

3. The question of pain (quidam cruciatus, ingens dolor) also comes into play when deciding whether or not a means is extraordinary. A common traditional example is amputation.

Moralists have always taken into account the element of expense (sumptus extraordinarius, media pretiosa, media exquisita). Expense can constitute an excessive hardship which in turn can make the means extraordinary.

Traditional moralists recognized the role that emotions of fear and repugnance (vehemens horror) could play. When fear is present, even when judged to be irrational and unwarranted, it can make a means extraordinary. Charmagne Loren L. Yerro It is not anything extraordinary in the nature of the treatment itself, but in the patient's reaction to the treatment, the burden the treatment imposes on him or on others. Cronin cited the Ballerini-Palmieri edition of Gury's moral theology which raises the question whether the use of anesthesia would render surgery "ordinary."

He thinks it is an open question.

This category of uehemens horror is one that has been overlooked in some of the bishops' statements on feeding and hydrating patients who are in a persistently vegetative state. Charmagne Loren L. Yerro The Consistent Ethic of Life: The Challenge and the Witness of Catholic Health Care by Joseph Cardinal Bernardin
Catholic Medical Center Jamaica, New York Life itself is of such importance that it is never to be attacked directly.
Second Vatican Council taught:
All offenses against life itself, such as murder, genocide, abortion, euthanasia, or willful suicide . . . all these and the like are criminal; they poison civilization. (Pastoral Constitution on the Church in the Modern World, 31) Guiding principles for the Terminally Ill patients: Life on this earth is not an end in itself; its purpose is to prepare us for a life of eternal union with God.

Consistent with this principle, Pope Pius XII, in 1957, gave magisterial approval to the traditional moral teaching of the distinction between ordinary and extraordinary forms of medical treatment.

In effect, this means that a Catholic is not bound to initiate, and is free to suspend, any medical treatment that is extraordinary in nature. The Consistent Ethic of Life: The Challenge and the Witness of Catholic Health Care by Joseph Cardinal Bernardin
Catholic Medical Center Jamaica, New York Charmagne Loren L. Yerro Guiding principles for the Terminally Ill patients: Charmagne Loren L. Yerro The Pennsylvania bishops' statement:

For example, the bishops write that "the patient in the persistent vegetative state is not imminently terminal (provided that there is no other pathology present). The feeding—regardless of whether it be considered as treatment or as care—is serving a life-sustaining purpose. Therefore, it remains an ordinary means of sustaining life and should be continued.” Erosion of the distinction: Erosion of the distinction: Charmagne Loren L. Yerro The bishops of the Maryland Catholic Conference :
"[a] medical treatment should not be deemed useless, however, because it fails to achieve some goal beyond what should be expected." For them, medically assisted feeding and hydration is useful as long as the patient is capable of absorbing the nutrients delivered by the treatment. Charmagne Loren L. Yerro Pope Pius XII, “Address of Reanimation” Acta Apostolicae Sedis 49 (1957) 1027-1033. Pope Pius XII said:
But normally one is held to use only ordinary mean - according to circumstances of persons, places, times, and culture - that is to say, means that do not involve any grave burden for oneself or another. A more strict obligation would be too burdensome for most people and would render the attainment of the higher, more important good too difficult. Charmagne Loren L. Yerro Said the little boy, "Sometimes I drop my spoon."
Said the old man, "I do that, too.“
The little boy whispered, "I wet my pants.“
"I do that too," laughed the little old man.
Said the little boy, "I often cry."
The old man nodded, "So do I.“
"But worst of all," said the boy, "it seems Grown-ups don't pay attention to me.“
And he felt the warmth of a wrinkled old hand. "I know what you mean," said the little old man.

Shel Silverstein The Little Boy and the Old Man By Sheldon Allan Silverstein But time went by.
And the boy grew older.
And the tree was often alone.
Then one day the boy came to the tree
and the tree said, 'Come, Boy, come and
climb up my trunk and swing from my 
branches and eat apples and play in my
shade and be happy.'
'I am too big to climb and play' said
the boy.
'I want to buy things and have fun.
I want some money?'
'I'm sorry,' said the tree, 'but I
have no money.
I have only leaves and apples.
Take my apples, Boy, and sell them in 
the city. Then you will have money and
you will be happy.'
And so the boy climbed up the
tree and gathered her apples
and carried them away.
And the tree was happy. Charmagne Loren L. Yerro Once there was a tree....
and she loved a little boy.
And everyday the boy would come
and he would gather her leaves
and make them into crowns
and play king of the forest.
He would climb up her trunk
and swing from her branches
and eat apples.
And they would play hide-and-go-seek.
And when he was tired,
he would sleep in her shade.
And the boy loved the tree....
very much.
And the tree was happy. The Giving Tree And so the boy cut off her branches
and carried them away
to build his house.
And the tree was happy.
But the boy stayed away for a long time.
And when he came back,
the tree was so happy
she could hardly speak.
'Come, Boy,' she whispered,
'come and play.'
'I am too old and sad to play,'
said the boy.
'I want a boat that will 
take me far away from here.
Can you give me a boat?'
'Cut down my trunk
and make a boat,' said the tree.
'Then you can sail away...
and be happy.'
And so the boy cut down her trunk
and made a boat and sailed away.
And the tree was happy
... but not really. But the boy stayed away for a long time....
and the tree was sad.
And then one day the boy came back
and the tree shook with joy
and she said, 'Come, Boy, climb up my trunk
and swing from my branches and be happy.'
'I am too busy to climb trees,' said the boy.
'I want a house to keep me warm,' he said.
'I want a wife and I want children,
and so I need a house.
Can you give me a house ?' 
' I have no house,' said the tree.
'The forest is my house,
but you may cut off 
my branches and build a 
house. Then you will be happy.' 'I don't need very much now,' said the boy.
'just a quiet place to sit and rest.
I am very tired.'
'Well,' said the tree, straightening
herself up as much as she could,
'well, an old stump is good for sitting and restin
Come, Boy, sit down. Sit down and rest.'
And the boy did. 
And the tree was happy.  And after a long time
the boy came back again.
'I am sorry, Boy,'
said the tree,' but I have nothing
left to give you -
My apples are gone.'
'My teeth are too weak
for apples,' said the boy.
'My branches are gone,'
said the tree. ' You
cannot swing on them - '
'I am too old to swing
on branches,' said the boy.
'My trunk is gone, ' said the tree.
'You cannot climb - '
'I am too tired to climb' said the boy.
'I am sorry,' sighed the tree.
'I wish that I could give you something....
but I have nothing left. 
I am just an old stump.
I am sorry....' Yap, Sara T. Withholding and Refusing Optional Treatments Yap, Sara T. Karen Ann Quinlan Yap, Sara T. Withholding or withdrawing life-sustaining medical treatment is considered neither homicide nor suicide. Yap, Sara T. Withholding or withdrawing life-sustaining medical treatment is considered neither homicide nor suicide. Yap, Sara T. The principle of patient autonomy requires that physicians respect the decision to forego life-sustaining treatment of a patient who possesses decision-making capacity.
Life-sustaining treatment is any treatment that serves to prolong life without reversing the underlying medical condition.
Examples:
mechanical ventilation, renal dialysis, chemotherapy, antibiotics, and artificial nutrition and hydration. Patient Autonomy Yap, Sara T. Difference between withholding treatment and assisted suicide Court Distinction Yap, Sara T.
Distinction between intentionally causing a patient’s death and allowing a patient to die as a result of the withdrawal of life-sustaining treatment
there is a legal consensus that both withdrawing and withholding treatment, if not wanted by the patient or ineffective, can be justifiable.
Courts have also upheld the validity of DNR (do-not-resuscitate) and other treatment limitation orders. Yap, Sara T. There are no limitations on the type of treatment that may be withheld or withdrawn
No distinctions between “ordinary” and “extraordinary” treatment
Ventilator withdrawal that may result in death is permissible
Parenteral nutrition and hydration may be withheld or withdrawn under the same conditions as any other form of medical treatment Yap, Sara T. Conducts discussions of treatment preferences
Provide emotional support to the patient and his family
Sign the documents related to withdrawal of treatment and assume full responsibility for its accuracy Role of Physicians Yap, Sara T. Be Familiar With Policies and Statutes
Most states leave specific treatment decisions to be decided between patient and physician
Each institution will have its own policies, and may have developed standard forms regarding life-sustaining treatment 8-Step Protocol to Discuss Withholding or Withdrawing Therapy Yap, Sara T. 2. Appropriate Setting for Discussion

3. Ask Patient and Family What They Understand Yap, Sara T. 4. Discuss General Goals of Care
Determine or reconfirm general goals of care
Examples are:
"Can we review our overall goals for your care?"
" Let me tell you what I understand you want as we plan your care"
Once general goals confirmed, specific life-sustaining treatment preferences can be discussed Yap, Sara T. 5. Establish Context for the Discussion
Classic misstatement on the part of well-meaning physicians is, "Do you want us to do everything?"
This highly euphemistic and misleading question fails to acknowledge context
When are we talking about?
Today, when the patient is quite healthy, or at the very end of his or her life when facing death?
"Everything" is much too broad and easily misinterpreted by families, especially when they feel "everything" has not, in fact, been done Yap, Sara T. 6. Discuss Specific Treatment Preferences
Use language that the patient will understand (use a medically skilled translator if necessary)
Give information in small pieces
Reinforce context in which the decisions will apply
Stop frequently to check for reactions, to ask for questions, and to clarify misunderstandings
Useful to discuss and recommend withholding or withdrawing specific treatments in light of the general or overall goals previously been established Yap, Sara T. 7. Respond to Emotions
During these discussions, respond to patient and family anxiety
Patients, families, and surrogates may be profoundly disturbed by subject matter being discussed
Parents, if the patient is a child, are likely to be very emotional and need support from the physician and other members of the health care team Yap, Sara T. 8. Establish and Implement the Plan
Next steps may be as simple as planning to discuss the subject again at the next visit, or convening a family meeting to further discuss the proposed treatment plan
They may be as complex as organizing nursing, social work, and chaplaincy intervention
Discuss treatment plans with other health care professionals so that the plans may be carried out in a straightforward and organized fashion
Write appropriate orders, document discussion in the medical record and talk about the plan with other members of the health care team Yap, Sara T. Describe the aspects of each life-sustaining treatment in a manner that conforms to the principles of informed consent
The problem the treatment would address
What is involved in the treatment/procedure
What is likely to happen if the patient decides not to have the treatment
The benefits of the treatment
The burdens of the treatment Informed Consent Yap, Sara T. A 72-year-old woman with metastatic colon cancer enrolls in a hospice program. She has an implantable cardioverter-defibrillator (ICD) for ventricular arrhythmias. While in hospice care, she asks her cardiologist to turn off the ICD. Case Yap, Sara T. Patient
adequate decision-making capacity
informed of the consequences of their request
Patient’s authority over his or her own body and right to refuse unwanted interventions
If the request still violates the clinician’s conscience, the clinician may opt to transfer care of the patient to another physician. Answer: Grant the patient’s request Yap, Sara T. ‪Ethics of health care: an introductory textbook‬ By Benedict M. Ashley, Kevin D. O'Rourke
Emanuel LL, von Gunten CJ, Ferris FD. Education for physicians on end-of-life care/Institute for Ethics at the American Medical Association
AAFP.org References Death and Dying A Report
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