The Nathaniel Centre

Spirituality, Suffering and Dementia

Michael McCabe
Issue 17, November 2005

Introduction

Some forty years ago the Second Vatican Council concluded its deliberations with the very beautiful document, "Gaudium et Spes" - "The Church in the Modern World". It contains many rich themes, not least, the nature and dignity of the human person and the communal or social nature of that human person. By his or her very nature the human person is not only to be considered "whole and entire, with body and soul, heart and conscience, mind and will" (Gaudium et Spes, n.3), he or she must also be considered as a being-in-community.

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End-of-Life Care

Dr Elizabeth Hepburn (IBVM)
Issue 17, November 2005

In Australia there has been a move in public hospitals to encourage the formulation of advanced care directives through a programme known as 'Respecting Patient Choices'. This programme has prepared a patient information sheet and also instituted a process by which the matters canvassed could be discussed with trained personnel. In its inception it has much to recommend it.

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The New Zealand Suicide Prevention Strategy 2006-2016 - A Critique

Michael McCabe
Issue 19, August 2006

The anguish and despair following the suicide of someone we love can be overwhelming. Two questions that we ask over and over are WHY and WHAT could we have done to stop them. At a national level, knowing that we continue to have high rates of suicide for some age groups compared with other countries raises the same questions; WHY and, as a nation, WHAT can we do about it.

--The Honourable Jim Anderton, Associate Minister of Health

Approximately 500 New Zealanders die each year by suicide and five times as many as this figure are hospitalised after a suicide attempt. Suicide in New Zealand is a serious problem annually more New Zealanders die this way than on our roads.

Eighty percent of all suicides in New Zealand occur with people aged 25 and over, with the majority of these deaths in the 25-44 year age group. While the young are particularly vulnerable to suicide the impact of suicide is felt across all age groups in New Zealand including the elderly and socially isolated, those who live in the most deprived areas of the country, the unemployed and those suffering from depression. Young Māori men and women have a significantly higher rate of suicide and hospitalisation for suicide attempts than non-Māori. Although more females are hospitalised after attempting suicide more males actually die by suicide.

The emotional devastation caused by suicide is profound for families as well as for the wider community. Suicide also has a major economic effect on the community. It is estimated that the annual cost of suicidal behaviour in New Zealand is nearly 1.4 billion dollars.

In his foreword to The Ministry of Health's recently published The New Zealand Suicide Prevention Strategy 2006-2016, Associate Minister of Health, the Honourable Jim Anderton hoped that the release of this new strategy will mobilise renewed efforts to work together to prevent suicide and suicidal behaviour. He noted that suicide prevention is complex and many would admit there is no quick fix to this social problem in New Zealand which affects so many every year. Nevertheless, with sustained and coordinated action at many levels in society, and with a variety of approaches, it is possible to achieve significant results in suicide prevention.

The Suicide Prevention Strategy builds on an earlier national strategy aimed at lowering youth suicide [The New Zealand Youth Suicide Prevention Strategy 1998.] The rate of suicide has decreased for young males as a result of this earlier strategy and there are more services and community resources in place to help the young and the wider community understand suicidal behaviour and suicide prevention.

In this latest strategy the focus has now expanded to all age groups, acknowledging the fact that suicide has a significant impact in other age groups, most notably in elderly males who have a higher rate of suicide than younger males. The prevention strategy outlines a framework that shows how the various activities across a range of sectors in the community can come together to prevent suicide across all age groups. Underpinning this framework is a fundamental vision of a society where all people feel that they:

• Are valued and nurtured
• Value their own life
• Are supported and strengthened if they experience difficulties
• Do not want to take their lives or harm themselves.

The strategy aims to reduce the rate of suicide and suicidal behaviour and equally to reduce the harms and impacts that are associated with suicide on families/whanau, friends and the wider community.

The seven goals of the New Zealand Suicide Prevention Strategy are to:

1. Promote mental health and wellbeing, and prevent mental health problems
2. Improve the care of people who are experiencing mental disorders associated with suicidal behaviour
3. Improve the care of people who make non-fatal suicide attempts
4. Reduce access to the means of suicide
5. Promote the safe reporting and portrayal of suicidal behaviour by the media
6. Support families/whanau, friends and others affected by a suicide or suicide attempt
7. Expand the evidence about rapes, causes and effective interventions

With some insight the strategy notes that while suicide is a serious health and social issue, and represents a significant loss to our society it is also an indicator of the social wellbeing of the population.

The importance of societal factors in suicide was recognised more than one hundred years ago by Sociologist Emile Durkheim in his 1897 book Suicide: A Study in Sociology. He was the first to discount non-sociological explanations of suicide. He sought to show that, what masked as a highly individual and personal statement, could be explained, in part, in terms of the degree of social integration within a particular society. He argued that suicide was an echo of the moral state of society and was in fact dependent on social causes and not on individual conditions even though the latter were a factor in suicide. For Durkheim, a high rate of suicide in a particular society or particular social group was in direct proportion to the lack of social cohesion in that society or that social group.

Examination of the World Health Organization's Map of Suicide Rates helps to illustrate this point. Countries with the highest rate of suicide include Australia, New Zealand, Russia, China, Eastern and Central Europe. Predominantly Catholic and Islamic countries have some of the lowest rates of suicide. Do these statistics reflect the more secular nature of our New Zealand society or are there other sociological factors beneath such disparity? Might a society that valued the transcendent have a better appreciation of the role of religion and faith in suicide prevention? The Suicide Prevention Strategy would be strengthened if there was wider recognition of the place of faith and spirituality and their role in helping to protect the vulnerable against suicide.

The strategy document does not address the issue of physician-assisted suicide or euthanasia and claims that this subject raises separate ethical, legal and practical issues. While the issues appear to be separate they are very much linked to the wider issue of suicide in society, as Durkheim implied so many years ago. This is particularly so when one considers a topic such as 'the meaning of life' from the perspective of the elderly.

In recent years the increase in numbers of the elderly is reflected in the growth of retirement communities which provide a continuum of care that ranges from independent living to rest-home and finally to hospital care. While retirement homes can offer wonderful care, a greater sense of security and opportunities for community living, they can unwittingly leave the elderly feeling isolated with minimal influence in society. To the extent that this is perceived as being true, or is true in reality, then some elderly may well feel that their lives have lost meaning long before they lose their lives. This perception may well predispose the elderly to greater risk of suicide. Because their physical frailty may limit their ability to commit suicide, voluntary euthanasia and physician-assisted suicide offer a false form of security.

Given the very high rate of suicide in elderly males in New Zealand it is timely to recall the fact that the calls for voluntary euthanasia and physician assisted suicide reflect a high level of suicidal ideation in this group as well as in the chronically and terminally ill.

Conclusion

The Suicide Prevention Strategy depends on adequate mental health services for all ages and therefore highlights the need for a deeper understanding of the mental health requirements of the elderly. Further, because voluntary euthanasia and physician assisted suicide is part of the pattern of suicide in our society, it has to be recognised and addressed for what it is a method of committing suicide.

The strength of the Suicide Prevention Strategy document is in the way it openly addresses a major personal and profound social problem in New Zealand. The prevention strategy rightly states that there are no quick fixes to a problem of such depth. Nevertheless, in recognising the social causes of suicide, even implicitly, and in providing a strategy to help prevent the untimely and devastatingly tragic death of New Zealanders, it helps provide a way forward for all in the society. Durkheim described this path as social cohesion. It can also be described as the path to stronger communities.

_____________________

Rev Michael McCabe, PhD
Director
The Nathaniel Centre

©
2006

Defining New Zealand Palliative Care: A Discussion Document

Nathaniel Centre Staff
Issue 19, August 2006

The challenges and needs of people at the end of life are multifarious. In the first instance the priority is to enhance quality of life by providing relief from pain and other distressing symptoms. This calls for a holistic approach to care that integrates the physical, psychosocial and spiritual dimensions, and that also takes account of the needs of families/whanau and other caregivers who are accompanying and caring for the dying person.

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Editorial: "The old, old story..."

Issue 23, November 2007

"Many a worker in a factory or shop has had a strange, beautiful and pious youth. But city life sometimes removes the 'early dew of morning.' Even so, the longing for 'the old, old story' remains. What is at the bottom of the heart stays at the bottom of the heart. In one of his books Elliot describes the life of factory workers, etc., who have formed a little community and hold religious services in a chapel in Lantern Yard, and he says of it, 'It is the kingdom of God on earth, no more and no less."

--Vincent van Gogh, Letter to Theo van Gogh 1876

In less than a month we observe the feast of Christmas – a day of pause and rest, a day for family and those in special need – a day to honour and to celebrate, in myriad ways, the birth of the Word made flesh. In the lead up to Christmas it is passé to hear commentary such as how "secular New Zealand has become", what a "commercial racket" Christmas is, and, how "stressful" this time of the year is with so many competing demands on one's valuable time. Thank goodness, it is said, we can all relax until the country "re-opens for work" at the end of January!

These perceptions generate challenges both in appreciating the light and the shadows of city life and because of the manner in which they powerfully reflect the loss of "the early dew of morning." Equally, they underscore the need to communicate insights and wisdom in fresh ways that resonate in the heart where the longing for the old, old story is still most keenly felt. Such is the challenge in theological bioethics whose role is to make the medical, ethical and moral relevant and understandable within specific cultures and according to a faith perspective. In the midst of the very real complexities of city life it is all too easy to react in a pragmatic and limited manner rather than returning, as we all must, to the old, old story of the Word made flesh written in Scripture and to be found deep within every human heart. Such a return may well generate fresh understanding to see that a so-called "secular" perspective may in fact reflect a deeper and existential longing for the old, old story by a different name.

The use and misuse of technology shapes much of our worldviews and many contemporary debates in biomedical ethics, not least our care of the dying. The use of technology in medicine has grown by geometric proportions as have the moral implications of its use. In the care of the terminally ill and the dying the overuse of technology is not only a way of doing things but also reflects a certain way of thinking. When used inappropriately technology can trigger ethical and moral consequences. In such circumstances both medicine and society are not always able to critique the issues that are raised in a comprehensive and life-giving manner. For these reasons we felt it timely to devote this complete issue of The Nathaniel Report to some current end-of-life issues.

Mary Schumacher, Chief Executive Officer of Hospice New Zealand, reflects on the challenges that the New Zealand hospice movement faces nearly thirty years after the first hospices were formally established. In this wide-ranging interview Mary Schumacher observes that within the rapidly changing context of healthcare delivery in New Zealand the boundaries between active curative treatment and palliative medicine have also blurred. Consequently different technical skills are required. Similarly the partnerships between hospice and other healthcare providers have also changed and the role of cooperating with, and working alongside the aged-care community become more critical particularly if all are to have access to quality palliative care.

In August 2007 the Congregation for the Doctrine of the Faith [CDF] published its response to questions concerning the use of artificial nutrition and hydration for patients suffering from the distressing and relatively rare condition of post-coma unresponsiveness [PCU] or the persistent vegetative state [PVS]. We reprint Doctor Ron Hamel's thoughtful and thought provoking response to the CDF's statement.

The teaching of the CDF and subsequent reflections on it from international theologians is a timely reminder that our commitment to the sanctity of life and the stewardship of the gift of life does not equate with the need to use technology at all costs or in every possible situation. Such a technological imperative could readily become vitalism by another name – life at all costs - and prolong the dying process unnecessarily. The Catholic moral tradition, as many notable theologians have reminded us over time, seeks the path of a "via media" – a path that is beautifully encapsulated in the philosophy of the hospice movement, namely, "to neither hasten, nor postpone, death."

Technology is not the primary means for managing or caring for the dying patient even though the judicious use of it is a central focus in ethical palliative care delivery. It has been said that the moral dimension of healthcare is that which leads us deeper into the mystery of our humanity. The care of the dying is a role for the whole community as it seeks to care for each patient in his or her uniqueness before God.

This communal role takes us necessarily into the spiritual realm without excluding the medical dimension of healthcare.

Good communication is the lifeblood of relationships and its lack can readily lead to a sense of loss and disconnection with the old, old story. Good communication is essential if family and healthcare providers are to honour the wishes of a particular patient, especially the terminally ill. Health and Disability Commissioner for New Zealand, Mr Ron Paterson, provides a timely reminder of the value of Advance Directives and their place in decision making at the end of life.

Sue Seconi's poignant reflection on a ten-year journey with her mother who was suffering from Alzheimer's disease reveals how she became aware of the gift of life and the giver of life at an even deeper level despite all appearances to the contrary. Hers, and similar stories of families caring for loved ones at the end of life, embody the core meaning of the old, old story of God among us – a story which fundamentally speaks of self-giving and presence especially in the midst of suffering.

Rev Michael McCabe, PhD
Director
The Nathaniel Centre

An Interview with Mary Schumacher

Issue 23, November 2007 

New Zealand's first hospices Mary Potter Hospice in Wellington, Te Omanga in Lower Hutt and Saint Joseph's (now Mercy) Hospice in Auckland, were opened in 1979. With over thirty hospices nationwide there is now widespread recognition and awareness of the hospice movement and of the need for, and availability of, palliative care for the terminally ill.

On 25 October 2007 I interviewed Mary Schumacher, Chief Executive Officer of Hospice New Zealand, and asked her about the remarkable growth of the hospice movement in New Zealand and the challenges that such growth presents.

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