Katholieke Stichting Medische Ethiek
15 augustus 2022

Omarm de laatste levensfase zoals Johannes Paulus II dat deed

Katholiek Nieuwsblad, 15 mei 2020
door Ingeborg C. M. Kleemans, specialist ouderengeneeskunde.

Paus Johannes Paulus II imponeerde niet alleen door zijn leven, maar ook door zijn sterven. Hij toonde hoe de mens ook in zijn broosheid waardevol blijft. Die les mogen we ons nog altijd ter harte nemen.

De laatste levensfase van de mens is een waarde­volle fase, waarin het menselijk bestaan in zijn kwetsbaarheid zichtbaar wordt. Paus Johannes Paulus II liet deze kwetsbaarheid tegen het einde van zijn leven aan de wereld zien. Hij leidde de Kerk als opvolger van Petrus zolang het leven op aarde hem werd gegeven. Het was een bewuste keuze van een paus die jarenlang vol energie aan het hoofd van de Kerk stond. In die laatste fase van zijn leven was hij vol wils­kracht, maar ook broos, en was zijn lijden goed zichtbaar.

CORONA

Voor mij is deze laatste periode van het leven van Johannes Paulus II een mooi voorbeeld van zorg die het leven respecteert en de dood ziet als een normaal proces. Een laatste fase die inder­daad gezien mag worden en waarover gesproken moet worden.

Maar is er tegenwoordig nog wel ruimte voor deze laatste levensfase van de mens, en voor het gesprek daarover?

Ik kom de broosheid van het leven dagelijks tegen in mijn werk als specialist ouderengeneeskunde in een verpleeghuis. Verpleeghuizen zijn in de huidige coronapandemie veel in het nieuws. De landelijke bezoekstop is een ethisch dilemma; hoe maken we de afweging tussen het aspect van de veiligheid van de groep en dat van de kwaliteit van leven van het individu?

De ouderdom komt met gebreken, bij het berei­ken van een hogere leeftijd ontstaan er nou een­maal lichamelijke en/of geestelijke tekorten. Hoe deze gebreken worden ervaren, hangt af van vele factoren. Niet in de laatste plaats van de persoon om wie het gaat zelf. Hoe staat iemand in het leven, wie of wat is voor hem belangrijk? Hoe gaat diegene om met tegenslagen in het leven? Zijn er betrokken naasten? Iedereen is anders en uniek, en juist daarin ook gewenst en geliefd door God. Helaas zie ik dat dit besef geliefd te zijn, bij velen afwezig is. Het lijkt er soms bijna op dat het leven als minder waard wordt gezien, wanneer je door lichamelijk of geestelijk verval niet meer kunt doen wat je wilt. Wie of wat maakt dat een leven waardevol is? En is dit meetbaar? Als ik deze vragen gesteld hoor worden, is het mij duidelijk dat de vraagsteller niet gelooft dat elk leven door God geschapen, geliefd en derhalve waardevol en kostbaar is.

We lijken te zijn vervreemd van het doodgaan als natuurlijk proces. Of willen we er geen tijd voor maken? Misschien omdat het ons met onze eigen kwetsbaarheid confronteert of een beroep doet op onze werkelijke beschikbaarheid voor de ander? Mijn ervaring is dat de laatste levensfase een waardevolle tijd kan zijn voor alle betrokke­nen. Een tijd waarin pijn en andere symptomen worden verlicht. Waarin de dood niet bespoedigd of uitgesteld wordt en waarin de patiënt tot het einde toe zo actief mogelijk kan blijven met maxi­male ondersteuning van familie of naasten. Het is een tijd waarin de essentie van het leven juist naar voren kan komen, als we ons daarvoor open durven stellen. Een tijd kortom, waarin we meer dan ooit zijn uitgenodigd om Christus te ontmoe­ten en zijn nabijheid toe te laten.

Diepe vreugde

Nooit heb ik meegemaakt dat iemand in de laat­ste levensfase prat ging op alle successen of het geld die hij in het leven verworven had. Wel maak ik dagelijks mee dat contacten met dierbaren leiden tot diepe vreugde bij alle betrokkenen – of dat het ontbreken van deze contacten leidt tot diep verdriet. Daadwerkelijk naar elkaar omzien, onbaatzuchtig en vol overgave: dat is wat elke oudere nodig heeft. De laatste levensfase moeten we blijven omarmen. Juist wanneer alles niet meer vanzelf gaat, is iedere persoon dit waard.


Overgenomen met toestemming van Katholiek Nieuwsblad.


Belgische bisschoppen: geen mens mag aan het eind van zijn leven in de steek worden gelaten

Katholiek Nieuwsblad, 19 juni 2019

Niemand mag aan zijn levenseinde in de steek worden gelaten. Dat schrijven de Belgische bisschoppen in hun nieuwe brochure “Uw hand in mijn hand – pastorale zorg bij het levenseinde“.

Met de brochure willen zij “vanuit het Evangelie oriëntaties aanreiken aan de velen die oude en zieke mensen nabij zijn, in het bijzonder de pastoraal werkenden”. Ze benadrukken hun waardering voor “al wie zieken en stervenden zorgend nabij blijven”.

Het verlangen om menswaardig te kunnen sterven is “een legitiem verlangen”. Over wat dat precies inhoudt, verschillen de meningen echter, vervolgen ze.

“‘Ge zult niet doen’, blijft voor ons – en overigens voor alle grote religieuze tradities – een richtlijn van vitaal belang. We komen op voor de fundamentele waarde van elk menselijk leven, zeker ook het meest broze menselijke leven.”

Een moeilijk spanningsveld

Attente aanwezigheid vormt volgens de bisschoppen de basis van de nabijheid, ook in situaties waarin mensen aangeven te verlangen naar de dood en euthanasie te overwegen. Ook dan “moeten we aanwezig blijven”. Dat “houdt geenszins een goedkeuring van euthanasie in. Voor de pastor kan dit een heel moeilijk spanningsveld betekenen”.

Ook in dergelijke situaties kan, zo stellen de bisschoppen, altijd voor en indien mogelijk samen met de betrokken persoon worden gebeden. Want “hoe groot onze menselijke onmacht ook is, altijd vertrouwen we onze medemens toe aan Hem die de bron is van alle leven en wiens barmhartigheid geen grenzen kent”.

Kanttekening bij ‘ondraaglijk lijden’

Bij het vaak aangevoerde “ondraaglijk lijden” kunnen volgens de bisschoppen wel kanttekeningen worden gezet. Zo kan de vraag gesteld worden of kwetsbare mensen wel voldoende aandacht krijgen, zo schrijven ze.

Ze doen een oproep aan pastores en vrijwilligers om hier alert op te zijn en nieuwe wegen te vinden om de betrokken personen nabij te zijn en te steunen.

God is bondgenoot van broze mensen

Volgens de bisschoppen helpt christelijk geïnspireerde zorg mensen ook om aan het eind van hun leven te kunnen loslaten, de balans op te maken en tegemoet te komen aan de nood aan verzoening en heling.

Wie stervenden begeleidt, moet proberen verbindend te werken, stellen ze: naar de naasten van de betrokkene, en als die ervoor open staat ook naar God “die de Bondgenoot is van broze mensen, ook al blijft Hij in de beleving vaak een ondoorgrondelijk Mysterie”.

De ziekenzalving

Ze benadrukken de rol van rituelen, die het onzegbare uitdrukken. Pastores moeten inspelen op de nood daaraan, zonder de sacramenten en typisch katholieke rituelen hun eigenheid te doen verliezen.

Ook vragen ze om het sacrament van de ziekenzalving niet pas aan het einde van iemands leven toe te dienen. “Het is een sacrament voor zwaar zieke of verzwakte oudere mensen. Zo heet het ook ziekenzalving, niet het sacrament van stervenden.”

Het verrijzenisgeloof

In het laatste deel gaan de bisschoppen in op het geloof in de verrijzenis. “Sterven als christen is je één mogen weten met Christus in zijn sterven én verrijzen.” Dat verrijzenisgeloof is echter “nooit een evidentie” en “ontkent alleszins de ernst van de dood niet”.

In de laatste levensfase wisselen veel verschillende emoties elkaar af, schrijven ze: “angst, protest, macheteloosheid, verdriet, maar ook genegenheid, hoop, dankbaarheid, aanvaarding… Dit alles kan ook in de godsrelatie tot uiting komen.”

De woorden die Christus op het kruis sprak kunnen dan “inspiratie bieden een heel herkenbaar worden. Gelovig sterven is je uiteindelijk aan Gods handen durven toevertrouwen”.

Overgenomen met toestemming van Katholiek Nieuwsblad.


Mgr. V. Paglia: Einde van het leven en palliatieve zorg

Abp. Paglia in Moscow talks about end of life and Palliative Care

Pauselijke Academie voor het Leven, 12 februari 2019

“A globalization devoid of Christian inspiration is poor in love and prey to conflicts; and the task of the Christian world is to re-center relations between people: Care means taking care of others, as the Gospel teaches. The parable of the Good Samaritan takes on a new dimension in the technological and hyper connected society whose implications are people “increasingly withdrawn into their own enclosures,” reiterated Abp. Vincenzo Paglia, President of the Pontifical Academy for Life.

Abp. Paglia was speaking in Moscow on Tuesday 12 February, as part of the annual “Colloquium” between the Catholic Church and the Patriarchate of Moscow to commemorate the Cuba meeting between Pope Francis and Patriarch Kirill, which took place in 2016. This year the Colloquium was dedicated to “end of life”.

Addressing the theme “At the service of human dignity, called to life” in light of Humana Communitas, the Holy Father’s Letter to the Pontifical Academy for Life, Abp. Paglia stressed that in “taking care”, “we must take care of human life in the sense of the human quality of the choices that guard and reaffirm the ultimate destiny of life” while at the same time caring for the environment. “We are called to rediscover tour connection to and relationship with the places that host our lives”.

After having framed the challenges posed by the specific theme of the “end of life”, Abp. Paglia focused on how the Pontifical Academy has inserted as one of the qualifying points of its commitment as Palliative Care.

Palliative Care accompanies people in the transition to death. It does not abandon the sick person, as is sometimes the case when it is deemed that there “is nothing left to do neither is it directed towards a “therapeutic obstinacy”.

Palliative Care teaches us that “we have no patients; we have people, with all their physical, psychological, cultural and spiritual baggage”. It recognizes “the presence of family members and of those who work for their health” alongside the sick.

Palliative Care “re-locates the suffering person, even those preparing for the passage of death, within his or her fundamental, familial and social relational dynamic. You cannot die alone! Experience has shown that the demand for euthanasia or assisted suicide is in almost all cases the result of the social and therapeutic abandonment of the patient. On the contrary, once a valid multidisciplinary acceptance of the patient has been put in place and the network of affective and professional relationships is positively involved, it is very rare to find a request for death “.

“Dear friends – concluded Msgr. Paglia – our discipleship of the Lord Jesus, healer of bodies and souls, entrusts us with responsibility for the lives of men and women, especially the youngest and poorest, of today and of future generations. It is a great challenge, due to the complexity of the world in which we live and the vastness of its horizon. Of course it cannot be reduced to a simple technological question. In this age of ours, Christianity can truly help the whole of humanity to grasp the challenges of life in an essential and elemental humanistic and spiritual dimension “.

Finally, Msgr. Paglia gifted the Moscow Patriarchate and the local Catholic Church a Russian translation of the Letter Humana Communitas.


Dienstbaar aan de waardigheid van de mens en geroepen tot het leven

Serving the dignity of man, and called to life

Address of His Excellency, the Most Reverend Vincenzo Paglia, president of the Pontifical Academy for Life

Moscow – February 12, 2019

Your Eminences, Most Reverend Prelates, Dear Professors,

I am pleased and honored to have this opportunity to speak on such an important occasion whose purpose is to bring about deeper understanding and fuller cooperation between the Catholic Church and the Patriarchate of Moscow and of the entire Russian Orthodox Church. During their meeting in Cuba three years ago, Pope Francis and Patriarch Kirill emphasized the importance of the Gospel and of the Christian faith in the construction of a more just and peaceful society, one that promotes “respect for the dignity of man, called to life.” It is important that we recognize this responsibility and take it on as a shared commitment.

I interpret as a providential sign the fact that I just returned from a stay in Cuba, where I attended the fourth International Conference for World Balance in Havana. It dealt with the question of a more human and more fair coexistence in our now globalized planet. I spoke to the participants about the meeting in Cuba between Pope Francis and Patriarch Kirill, as well as about this conference, which takes its inspiration from the Joint Declaration that the Pope and the Patriarch signed.

We find ourselves now at a moment in history that requires greater unity among Christians because globalization without Christian inspiration is lacking in love and is prey to conflict. And unfortunately, that is what we often see today. The moment in history that we are passing through is characterized by people retreating into their own closed circles. We see everywhere an increased danger of an individualism that weakens both society and religions themselves. It is urgent for ChristiansCin a globalized worldCto offer everyone that vision of the unity of humanity that permeates the Gospel.

 

The collapse of “us”

In fact, at the beginning of the 21st century, society is characterized by some of the negative results produced by modern Western culture and imposed by it on the rest of the world. These results are now centered on a contradiction that undermines the hopes for Christian humanism. While on the one hand, recent centuries have seen increased attention to the person, and the person’s irreplaceable and priceless uniqueness and desire for a well-lived life, on the other hand we see an explosion of individualism that leads to loneliness, self-referentiality, and embitterment against society. Some philosophers such as, for example, Gilles Lipovetsky, speak of a “second individualist revolution” marked by the worship of hedonism and of psychology, by the privatization of life and by the triumph of autonomy over collective institutions. Zygmunt Bauman, one of the most careful students of social phenomena, spoke recently of a “fluid society,” a society with no fixed values.

Contemporary man, obsessively concerned with his personal destiny, is at risk of such an overwhelming narcissism that he is insensitive to those around him and no longer has the inner strength to commit himself to building a shared human community. The passion for humanity’s condition and “common destiny,” which nourishes an aspiration for “universal brotherhood,” has weakened and became uncertain. We could speak of what I call “the collapse of ‘us,’” that is, the loss of a common dream, of common vision.

The men and women of today are more connected, but not for that are they more brothers and sisters. If on the one hand technology and the economy have more or less bureaucratically unified societies, they have on the other hand disrupted them emotionally: pressure for functional efficiency kills relationships. We are looking at plan for the cultural and social “creation” of the individual as an end in himself, disconnected from any individual uniqueness and any possible separate “empowerment.” In the search for autonomy, the contemporary individual removes, day after day, the memory of the roots and bonds that generated and constructed him as a human person. Some speak of a new religion, “egolatry,” the cult of the ego, on whose altar the most sacred affections are sacrificed. The deterioration of social bonds, in all their aspects – family, work, culture, politics – is one of the most critical effects of the global diffusion of this individualism that has no others and no history.

 

Humana Communitas

Pope Francis, on the recent celebration of the 25th Anniversary of the creation of the Pontifical Academy for Life, wrote us a letter entitled Humana Communitas. We have translated it into Russian and want to give it to Patriarch Kirill and to all of you. In the letter, the Holy Father asks questions about the life of man and points out the (theological) roots that can serve as reference points when addressing the questions and difficulties that confront life itself. He explicitly and clearly points to the human community as the most complete and genuine locus for the free and conscious development of every man and woman. This is what the Pope writes: The human community is Gods dream even from before the creation of the world (cf. Eph 1:3-14). In it, the eternal Son begotten of God the Father has taken flesh and blood, heart and emotions. Through the mystery of giving life, the great family of humanity is enabled to discover its true meaning. (HC1). This dream …is what Jesus has entrusted to the Church and has placed in the heart of every person: the whole human family has a common origin and a common destiny. In a globalized world, the unity of the human family is the horizon that must involve all peoples. It is crucial to rediscover brotherhood, which unfortunately has not yet been achieved. Life is not an abstract universal; life is each person from his conception until the moment of death. Life is the whole human family all over the world. This is life, an historical reality.

And further on the Pope says: Indeed, the many extraordinary resources made available to human beings by scientific and technological research could overshadow the joy of fraternal sharing and the beauty of common undertakings, unless they find their meaning in advancing that joy and beauty. We should keep in mind that fraternity remains the unkept promise of modernity. The universal spirit of fraternity that grows by mutual trust B within modern civil society and between peoples and nations B appears much weakened. (HC13)

In the web of relationships that are part of the life of contemporary individuals, the fundamental questions that fill their hearts, their minds, even their bodies, and that are otherwise incapable of being answered exhaustively, must be included. Even the pressing question of rights, in order that it not become simply a declaration of intent, needs to be raised, justified, communicated and implemented, not with reference to an unconnected “I” but rather with broader reference to a human “us.” Without a harmonious correlation, without shared rights and duties, the proper protection of the person and his inherent dignity is not guaranteed, and the life of the community is not more human. One example: too often we witness the reduction of the great theme of humanity’s aspiration to happiness to the search for psycho-physical gratification, which becomes the sole criterion for and measure of everyday “quality of life.” In fact, to think about it, true well-being is what wells up from mutual love, from being well-loved, that is, loved and able to love, welcomed and welcoming, mercied” (as Pope Francis likes to say) and merciful.

The challenge that the lives of the more than seven billion people alive today offers us is that of the “us”: that is, rethinking ourselves within a web of relationships that certainly marks, limits, and imposes itself, but precisely for this reason does not abandon the other, that continues to reproduce, remains in solidarity, and hopes for a salvation that can reconcile us, all together, in shared and hopeful life.

There are two initiatives that I believe are fundamental in this area. The first deals with relocating the questions that must be asked about human life into the broader global perspective that is obligatory today. It is objectively illogical and unproductive to deal with the analysis of individual questions without first placing them into a framework within which, as far as possible, the complexity of the current situation can be taken into account. Today, in respect for, in defense of, and in the promotion of human life, everything is under consideration: local symptoms cannot be treated if global causes are not taken into account. Global bioethics is the current vehicle for examining the human quality of the choices intended to protect and reaffirm the ultimate destiny of life: resistance to addressing the radical understanding of this activity would be a serious misunderstanding of the responsibility that faith has today.

The second initiative is instead an extension of that theme. In recent decades, quite rightly, attention has been given to conditions on our planet and to the consequences of human activity on the environment. Today, it is time to widen this attention, to turn from a consideration of our common home to concern for its inhabitants. Precisely because the habitability of the planet is put into crisis by the reckless and selfish actions of its inhabitants, the time has come to concern ourselves seriously with this behavior. We are called to rediscover the connection between the relationships among us on the one hand and our relationships with the places in which we live on the other.

Accompany in the passage of death

In the context of our discussions, a unifying social understanding of death is particularly important. What troubles me deeply about the demand for approval of the various modalities of euthanasia is not simply the fact that there is a desire to pervert the practice of medicine, which should be entirely dedicated to the patient’s life and not to his death, but rather the fact that a person who, at a particularly serious and difficult time in life, asks to die.

The task of accompanying those who approach the sensitive passage from earthly life to a definitive encounter with Heavenly Father has an importance that is not limited to those immediately involved, but rather has much broader implications. It is the expression of a caring that finds the proper balance between the use of available medical resources and the search for the integral good of the person, in his familial and social context. In fact, the progress of science in the biomedical field risks making healing almost the main, if not the exclusive, purpose of contemporary clinical practice. This evolution brings with it the risk of focusing on the fight against disease and neglecting (or eliminating) the patient. At that point, we forget that the deepest meaning of therapeutic efforts (curing) is found in a relationship centered on taking care of the patient (caring). The tendency, especially in strongly technological contexts, is to look at the elimination of disease as the only objective to be pursued.

This attitude, in its turn, has two consequences. First, there is the risk of being unreasonable in the use of medical treatments, in order to obtain a healing that “must” be achieved at all costs, because in any failure to heal is seen as a defeat for medicine. Doing this, however, opens the way to the stubbornly unreasonable adoption of excessive measures. We can end up inflicting suffering on the patient by using means that are invasive and losing sight of the integral good of the person. Doing everything possible (if this is understood as always using all available means) can mean doing too much (that is, an excess that damages the patient).

The second risk is abandonment of the patient when a cure is no longer possible. Once that happens, the relationship between the doctor and the patient ends, and medicine (society) no longer has anything to do for him. This is an unacceptable course of action. If we cannot heal, we can still relieve pain and suffering and continue to take care of that person. The incurable patient is never to be left uncared for. This total commitment to care springs from a conviction that every person is endowed with absolute dignity at every stage of his life. We cannot speak seriously about the humanization of medicine unless we have an effective understanding of the dignity of every unique human person, even when seriously ill or near death. The risk that the incurable patient runs today is the risk of abandonment due to the idea that “Oh well, there is nothing left to do” or that “It’s not worth the effort.” Another risk that is the other side of the coin is euthanasia, based on the idea that if there is nothing that can be done, we might as well “get it over with.”

The firm refusal to adopt such courses of action finds a strong ally in palliative care. Recently, the international scientific community has approved (and the Academy for Life has been among the supporters of this development) a new definition of palliative care. It begins by stating that: “Palliative care is the active holistic care of individuals across all ages with serious health-related suffering due to severe illnesses, and especially of those near the end of life. It aims to improve the quality of life of patients, their families and their caregivers.

Two aspects of this definition seem particularly significant: the first is the holistic approach that palliative care offers, which is the exact opposite of a medical reduction in care. We don’t have patients, we have people, with all their physical, psychological, cultural and spiritual baggage. It is only within a framework that takes into account the whole of the human person, that technology, which is particularly efficient today, finds its true effectiveness, expresses its true strength.

The second aspect presented by the new definition of palliative care is that it recognizes, not only the person being treated but also family members and healthcare professionals, with the interesting proviso that they are not simply agents in the treatment of the person who is ill, they themselves are recipients of specific and caring attention. This formulation is crucial precisely because it keeps the suffering person, even one who is approaching death, within the circle of his fundamental family and social relationships. It is unthinkable to die alone! Experience has shown that the request for euthanasia or assisted suicide is in almost all cases the result of the patient being abandoned by society or the medical profession. To the contrary, once a true multi- disciplinary treatment protocol has been put in place and a network of affective and professional relationships created, it is very rare to encounter a death request.

Medicine must recognize the value of its fundamental vocation to “take care” and breathe new life into that vocation. We need to overcome the misunderstanding that equates “palliative” with “useless” or ineffective. This confusion explains some of the resistance that hinders the practice and acceptance of palliative care, even when its importance is recognized in principle.

Among the different levels and participants involved in a “taking care” that is reintroduced in a specific case, thanks in some way to palliative care, special attention is to be given to spiritual and religious questions and the persons (chaplains, spiritual counselors) who deal with them. For the believer, death always takes the form of a radical surrender to the mystery of God who does not abandon His children to the grave; moreover, the last days of the earthly life of every human person are a precious and irreplaceable opportunity to take stock of their existence and speak words of reconciliation and forgiveness. To assist and accompany a dying person (and that person’s family!) in this twofold transition is a precious gesture that gives added value to even the final moments of a person’s life.

Dear friends, following the Lord Jesus, healer of bodies and souls, confers on us the responsibility for the lives of men and women of today, especially the youngest and poorest, and of future generations. This is a great challenge because the world we live in is complex and its horizons are vast. This responsibility cannot be reduced to a simple technological process, but I can assure you that Christianity can really, in our time and within a humanistic and spiritual framework that is essential and inescapable, help the whole of humanity to answer the challenges of life. And this is one or the reasons we are here today. Together.

Thank you.