BLOOMFIELD HILLS, Mich. — Bernadine O'Dea was a good Catholic. She knew at the end of her life she didn’t want to hang on, plugged into tubes and machines that weren’t going to do any good.

So, when the senior living center gave her a living will to fill out, she checked all the boxes that indicated they were extraordinary care: antibiotics, cardiac resuscitation, mechanical respiration, feeding tubes, intravenous fluids, chemotherapy and kidney dialysis.

Fortunately, the 85-year-old Michigan woman trusted her son and handed it to him to check, Mike O'Dea recalled. He’s still appalled by the possibility that his mother could have inadvertently signed her life away.

Mrs. O'Dea’s living will didn’t just authorize the withdrawal of those treatments if she was dying; it also would have applied if she was permanently unconscious or, as the document stated, conscious but had "irreversible brain damage and will never regain the ability to make decisions and express my wishes."

Five years later Mrs. O'Dea died, with her son and his family by her side. But before that, she needed antibiotics and intravenous hydration and recovered to live another three years — very fully, O'Dea said.

Those treatments would have been denied her under the terms of the form she originally filled out, noted O'Dea, founder and executive director of the Christus Medicus Foundation in Bloomfield Hills, Mich., an organization that promotes authentic Catholic healthcare.

"Everyone’s situation at the end of life is different; they can’t put it in a document. Most people will check off ‘I do not want,’" he said.

Terri Schiavo, the brain-damaged Florida woman who was denied food and water because her husband maintained she would not want to be kept alive by artificial means, did not express those alleged wishes in writing. Her case has led to a rush to fill out living wills, which are easily available on insurance company and state government websites and often handed out to patients at hospital admission.

But pro-life activists and many Catholic ethicists, including the National Catholic Bioethics Center, the Catholic Medical Association, the National Right to Life Committee, and the International Task Force on Euthanasia and Assisted Suicide, say a standard living will is a very bad idea. The best option, they say, is another form of advance health care directive — a durable health care power of attorney.

‘Blank Check’

"What a lot of people call ‘a living will’ is the document that is like a blank check to an unknown physician," said Rita Marker, an attorney and executive director of the International Task Force.

With an increasing trend in hospitals and society to judge "futile care" based on quality of life, the "living will" becomes dangerous, National Right to Life ethicist Burke Balch said.

The federal Patient Self-Determination Act of 1990 requires all hospitals and health care facilities to provide written information to the patient about the right to accept or refuse medical treatment and the right to formulate an advance health care directive.

An advance health care directive can also be a durable power of attorney, with which a person designates an agent to act on his behalf if the patient is unable to do so.

"The agent should know the teachings of the Church and possess the practical wisdom to apply them to changing circumstances," said Dr. John Haas, president of the National Catholic Bioethics Center in Philadelphia.

Dr. Steven White, president of the Catholic Medical Association, recommends that Catholics nearing death — or their agents — consult with their physician and pastor about appropriate application of the Catholic teaching on ordinary and extraordinary care.

The International Task Force offers an entire packet for a durable health care power of attorney, and emphasizes compliance with each state’s laws as well as the need to revoke any prior directives. The National Right to Life Committee offers forms by state called Will to Live, and the National Catholic Bioethics Center offers a form as well as a pamphlet discussing the issue from a Catholic perspective.

Those are all different from the "living will" format now widely available. Managed care health insurance mega-companies such as Blue Cross-Blue Shield, United Healthcare and Kaiser Permanente either provide forms on their own sites or link to state websites with the forms. Compassion & Choices, a right-to-die group, offers downloadable "living wills" on its website.

Who Decides?

Without a designated health care proxy, a spouse is the legal decision-maker in all 50 states. But after that, states have differing rules over who will make health care decisions for a patient unable to make his own choices.

In many cases, even in the absence of a spouse, parents are not automatically the decision-makers for those 18 and over, Marker said. That is why it is important to fill out a durable health care power of attorney, she said.

More and more hospitals are relying on "futile care" standards, warned Balch, director of the Powell Center for Medical Ethics in Washington, D.C.

"So instead of denying treatment because it won’t work, they are denying it precisely because it would work, because it would preserve a life that they don’t consider is worth living," Balch said.

"Denial of food and fluids to people who cannot speak for themselves has been going on for 15 years in this country," Balch writes on the NRLC website. "It is routine practice in hospitals and nursing homes across the country. And for over a decade, the law on this, established by numerous court decisions and statutes, has been largely settled."

Living in a culture where the law favors euthanasia, Americans need protection to ensure that it won’t be practiced on them.

Catholics need to remain in conformity with Church teaching on the use of ordinary and extraordinary means, Haas said. He writes, "Human life is an inviolable gift from God. Our love of God and His creation should cause us to shun any thought of violating this great gift through suicide or euthanasia."

Food and fluids, even if they are delivered by a tube through the nasal passage or directly into the stomach, are not considered extraordinary medical treatment.

Pope John Paul II said as much in his address to the participants in the international congress on "life-sustaining treatments and vegetative state: scientific advances and ethical dilemmas" on March 20, 2004.

"I should like particularly to underline how the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act," the Pope said. "Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper purpose, which in the present case consists in providing nourishment to the patient and alleviation of his suffering."

Legionary Father Thomas Berg, an ethicist and executive director of The Westchester Institute in Thornwood, N.Y., explained that the Pope’s March 2004 statement provided much greater clarity to the issue.

"First of all, it places nutrition and hydration (even when artificial) in the category of normal care giving," he said. "Even when artificially administered, it is not to be considered a medical treatment. As a means of care giving, as the Holy Father points out, it should be continued until this is prudently judged to be ‘unduly burdensome’ for the patient, as was stated in 1995 by the Pontifical Council for Pastoral Assistance in its Charter for Health Care Workers.

"The normal instance of nutrition and hydration constituting an ‘undue burden’ to the patient is exemplified when such care has become futile because the patient’s body can no longer assimilate them. There may be other circumstances which, in harmony with Catholic teaching, constitute an undue burden for the patient and which may warrant the temporary or permanent withdrawal of nutrition and hydration."

Father Berg further noted that this same document clearly states that the undue suspension of nutrition and hydration would constitute "real and properly so-called euthanasia" (n. 120).

The Catechism of the Catholic Church states: "Direct euthanasia consists in putting an end to the lives of handicapped, sick, or dying persons. It is morally unacceptable.

"Thus an act or omission which, of itself or by intention, causes death in order to eliminate suffering constitutes a murder gravely contrary to the dignity of the human person and to the respect due to the living God" (2277).

Father Berg explained that what are normally referred to as "extraordinary means" of medical treatment may be legitimately refused when the patient or (if the patient is no longer able to make the determination) the designated healthcare proxy prudently considers them to constitute an undue burden with no proportionate benefit to the patient foreseeable, especially when the person is imminently dying.