EXTRA-ORDINARY MEANS

There is a great deal of debate about extraordinary means. Perhaps a few words from someone who has practiced medicine, surgery and psychiatry may help to clarify the issues. This should not be considered a reflection on any current case.

The fundamental principle that determines whether a given treatment is extraordinary is whether or not what is being treated is reversible. To maintain and prolong the life of a terminal patient by artificial means is like beating a dead or dying horse. Such never prolongs life – rather it only prolongs the process of dying. 

If the situation is unclear as to whether the individual is terminal or not, (not as common as some would think), it behooves the physician to consult with the patient and family, and then to use his best judgment – a judgment honed by experience and maturity.  In such cases a physician will often seek the opinion of a fellow practitioner.

Consider the use of a ventilator (respirator). A patient with a treatable pulmonary infection or Guillain Barre syndrome may be placed on a ventilator in anticipation of recovery. In a similar manner, a patient in irreversible respiratory failure without hope of recovery may also be placed on a ventilator. In the first case one saving a life; in the second one is only prolonging the process of dying. It is clearly the intention and the situation and not the technique which determines whether or not the means is extraordinary. 

Again, consider the decision to use a feeding tube. In an individual who has reversible coma such as can result from a car accident, the use of a temporary feeding tube is both legitimate and necessary. Somewhat different is the use of a feeding tube in a patient with confirmed irreversible coma. Similarly, terminal cancer patients often fail to take in sufficient nutrition.  The refusal of such patients to eat is part of the involution that occurs approaching death.  Force feeding them is in some ways a cruel act. (Providing enough water to maintain a reasonable level of comfort is another matter, for keeping the individual comfortable is always to be desired.)

There are then situations where the physician and or the patient decides that no further medical intervention is inappropriate, where the natural process of dying should be allowed to take its normal course. In an earlier time it was said that “pneumonia was the old man’s friend.” Such is the basis of the oft used order “Do not resuscitate.”  This situation, which is by nature “passive,” must be clearly distinguished from suicide and euthanasia where a positive act on the part of the patient or physician is involved. 

Normally, it is for the physician to determine whether a given intervention is extraordinary or not; appropriate or not. In an earlier time when the family physician was a trusted friend and family advisor, few problems arose. Today with the departmentalization of medical services and the resulting depersonalization of care, such decisions have become more difficult.  Nevertheless, such decisions should be made by physicians and not by theologians, politicians and so-called ethicists. Physicians should of course involve the patient (whenever possible) and the close family in such decisions. Can a physician be wrong in his judgment? Physicians are constantly called upon, by the nature of medical practice, to make judgments where they can be in error. Certainly this is a possibility. In difficult cases usual hospital practice often requires that two physicians who have no connection with the case be asked to make such an evaluation. Very often, when in doubt, physicians will ask themselves whether the course of recommended action is one they would wish for a parent or for themselves. Making such decisions is part of the responsibility of their vocation.

It should not be forgotten that terminal patients should have the benefit of extreme unction (or if Protestant or Jewish, the benefit of their minister). While it is preferable that this occur while the individual is conscious, such services should be offered “conditionally” if the individual is no longer able to respond. Pius XII made it quite clear that after these spiritual obligations are fulfilled, the patient should be given every necessary physical support and made as comfortable as possible.

Fr. Rama P. Coomaraswamy, M.D., F.A.C.S.