University Hospital merger stirs end-of-life care fears (KY)

A growing chorus of protest from local residents, doctors and others has erupted over the fact that Catholic doctrine could override patients’ end-of-life wishes under a pending merger of three Kentucky hospitals.

Under the merger proposal, University Hospital will join Jewish Hospital & St. Mary’s HealthCare and St. Joseph Health System, whose parent company is Denver-based Catholic Health Initiatives. CHI will own 70 percent of the combined operations, assuming regulators approve.

When the merger was announced last month, officials said all the merged hospitals will follow Catholic health care directives. And while many wealthier patients could simply choose a different hospital, indigent patients have little choice but University Hospital for treatment, including end-of-life care.

That has left some worried about how end-of-life decisions will be affected if living wills and decisions to remove a feeding tube, for example, will not be honored if they are “contrary to Catholic teaching.”

“I don’t like what I’m hearing with this merger; patients have rights till the day they die,” said Lorri Keeney, whose 88-year-old mother died of natural causes in a nursing home under hospice care through Hosparus in May 2010 after numerous hospital visits. “I would’ve taken my mother out of the hospital if they had told me I had to abide by their doctrine.”

Keeney’s mother, Eleanor Caram, was Jewish and had a living will. But Catholic medical directives, which merger partners have agreed to abide by, say living wills won’t be honored if they go against Catholic moral teachings, which are open to interpretation.

“She would have been totally against this,” said Keeney, 56, of Louisville. “Her belief system was different. She was very firm in what she wanted.”

Reproductive services

Dismay over the merger’s possible effect on reproductive care led more than 450 people to sign a newspaper advertisement asking officials to change the merger’s terms. Catholic rules forbid sterilization, non-natural birth control and abortions — meaning, for example, that low-income women or those with high-risk pregnancies could not get a tubal ligation at University at the same time as their delivery.

Officials at the University of Louisville, which trains doctors at the hospital, and the participating hospitals assured the community that a full range of reproductive procedures will continue but haven’t spelled out how that can occur while honoring the Catholic directives.

“The Catholic church has decided everyone has to act like pious Catholics,” said Dr. George R. Nichols II, who was Kentucky’s chief medical examiner for 20 years ending in 1997. “The public trust has been destroyed. … I don’t trust (the merger partners) for anything. That was lost when they negotiated this deal.”

Nichols and several other merger critics and skeptics say they are especially disturbed because University Hospital — the region’s safety net for the poor — received $61 million from the state and $7 million from the city last year for indigent care.

Officials at University Hospital and Jewish Hospital referred questions about how the directives might affect care there to CHI, with University officials adding in a statement that the hospital “follows all national guidelines and state laws regarding end-of-life care” and honors living wills and the wishes of patients and families.

In a statement, CHI officials said living wills, or advance directives, would be honored “in the vast majority of cases.”

“There may be the rare situation, such as a patient in a persistent vegetative state who is not in the dying process, when what the patient is requesting through his or her advance directive is not consistent with the moral teaching of the Church,” the statement said. “In those few cases, a Catholic health care facility would not be able to comply, and with the family’s guidance, the patient would be transferred to another facility, or to their home under hospice and family care.”

But Keeney said Catholic doctrine shouldn’t rule at a public hospital. “It doesn’t belong there.”

Living will exemptions

Kentucky law requires health care officials to honor a living will, which can outline when someone does or doesn’t want life-saving measures to be taken or withdrawn.

But state law allows an exemption for doctors, nurses or health care facilities that disagree with a living will on religious grounds. In that case, they cannot be held liable for refusing to honor the wishes of a patient or family members.

The Catholic directives, developed by the U.S. Conference of Catholic Bishops, say a competent adult’s decision to withdraw life-sustaining care “should always be respected and complied with” — but not if that decision is against Catholic moral teaching.

Another directive says there is normally an obligation to give patients food and water, including those in a “persistent vegetative state,” but suggests that nutrition and water may be withdrawn if they cannot be expected to prolong life or comfort.

Dr. George Webb, who trains volunteers and does other work for Hosparus, said he has not experienced differences in how Catholic and non-Catholic health care facilities have dealt will terminally ill patients.

“I can’t (recall) any time when our views were in opposition with what the hospital views were, as far as end-of-life care goes,” Webb said.

He added that if a family or patient’s wish to disconnect a feeding tube is against a hospital’s policy, the family always has the option of transferring the patient to another facility.

But Arthur Caplan, director of the University of Pennsylvania Center for Bioethics, said that it’s not always that simple and that uncertainty and differences of opinion are common in hospital mergers involving secular and religious institutions.

“It will depend on hospital administrators and how vigorously they are going to follow the teachings,” Caplan said.

Lois Uttley, director of the MergerWatch Project, a New York patients’ rights organization that tracks secular-religious mergers, said senior citizens frequently ask her how mergers might affect their final days.

“The answer is uncertainty,” she said. “Who decides what is contrary to Catholic teaching? … It often depends on your local bishop.”

Food and water

Following the controversy surrounding Terri Schiavo, a young woman who spent years in a severely compromised neurological state, the conference of bishops last year amended a directive about providing terminal patients with food and water. The new language said the obligation for feeding “extends to patients in chronic and presumably irreversible conditions (e.g., the ‘persistent vegetative state’) who can reasonably be expected to live indefinitely if given such care.”

State Rep. Mary Lou Marzian, D-Louisville, a transplant nurse, said if all decisions to withdraw life-sustaining procedures were subject to Catholic teaching, “you’d have the tragedy of Terri Schiavo all over again.”

Marzian added: “If they have this merger and the Catholic directives are enforced for end-of-life care, it could be a real interference in people’s lives that have made decisions about their own end-of-life care, that may or may not be Catholics.”

Virginia Woodward, who was involved in organizing the newspaper ad seeking a change in the merger’s terms, said end-of-life decisions should be left to families.

“They’re heart-rending. It’s tough in the best of situations,” she said. “And if you have other entities trying to insert themselves over what’s appropriate and not appropriate beyond what a physician is recommending and what the family wishes are, that just makes a terrible situation horrendous.”

She said she’s concerned about anyone trying to intrude on those decisions. “And I don’t know how you are a public hospital that is financed with tax dollars from state, local and federal (governments) and also honor the religious beliefs of some large conglomerate.”

Public discussion

Many observers said more transparency is needed. Hospitals need to communicate about their plans, they said, and patients need to know what they are getting into when seeking care.

“Ask lots of questions when you’re admitted to a hospital, then make your best decision” about whether to go to that hospital, said MergerWatch’s Uttley.

But low-income residents without insurance have fewer options when choosing a hospital. University Hospital is sometimes the only option.

Last month, representatives of the Louisville Board of Health met with the merger partners to air concerns about whether current levels of access to care would continue. One issue they discussed was end-of-life care.

William Altman, the board’s chairman, said Friday that he trusts the merger partners’ broad assurances that access won’t be diminished and patients’ rights will be respected “as they are now.”

But he said it’s time for the merging organizations to give the public details about how it will do that while complying with the Catholic directives.

“The time for the public discourse about the specifics … is now,” Altman said.


University Hospital merger stirs end-of-life care fears
Hospitals’ Catholic directives could conflict with patients’ wishes
Laura Ungar/Patrick Howington
July 23, 2011
The Courier-Journal