Pontiff’s Choice Was to Die Simply

Pope John Paul II died the way he wanted.

He spent his final hours in his Vatican apartment, surrounded by nine members of his mainly Polish inner circle. Three doctors were present, but no elaborate hospital technology to help prolong his life.

Just before the end, the pope’s longtime secretary celebrated Mass and began to anoint the pope’s hands with oil, according to one account. John Paul gripped his secretary’s hand, an apparent farewell gesture to a faithful aide who helped the pontiff fulfill his wish to die unencumbered by tubes and machines. It was 9:37 p.m. Saturday.

The cause of death was septic shock and irreversible heart failure, according to the death certificate made public Sunday by the Vatican. John Paul’s decision last week not to return to the Gemelli Polyclinic hospital where he had spent so much time in recent years mirrored decisions made every day by severely ill patients and their families.

His very public choice also highlighted profound moral questions within Catholicism about the balance of preserving life and accepting death.

The debate has intensified with advances in medical technology. Church teachings simultaneously emphasize the sanctity of life as well as the acceptance of the final embrace of God. The pope’s ordeal has raised comparisons with the recent ethical and theological battles over the Terri Schiavo case, though churchmen and theologians said Sunday that his struggle was different because he was in a position to help dictate the terms of his final medical care and she was not.

John Paul’s final hours, as described by doctors, churchmen and sources close to his inner circle, did not include aggressive efforts to revive him as his organs failed. No kidney dialysis machine was used in his apartment, and the insertion of a sophisticated feeding device in his stomach would have required a return to the hospital, sources said. Instead, doctors said, they relied mainly on antibiotics and a respirator.

“There were no therapeutic extremes,” said Rodolfo Proietti, a longtime anesthesiologist on the pope’s medical team, quoted Sunday in the Corriere della Sera newspaper.

Proietti and the pope’s personal physician, Renato Buzzonetti, supervised John Paul’s care in the final days, according to a doctor who recently treated the pope and asked not to be named.

The pope, assisted closely by Archbishop Stanislaw Dziwisz, his longtime secretary, played the central role in the decision-making, the doctor said. It was Dziwisz who held the pope’s hand when he died, according to Father Konrad Hejmo, a Polish monk who later spoke to those present at the pope’s bedside.

When the pontiff left the hospital March 13 after doctors performed an operation to ease his breathing, he made it clear to his aides that he did not intend to return.

Like many gravely ill people, the pope preferred to face death at home, not in the fluorescent glare of a hospital. His choice, according to a source close to papal aides, also reflected his keen awareness of church history and ritual: Popes die in the Vatican.

That determination and the ensuing medical choices were consistent with church teaching about not prolonging life at all costs, according to theologians.

“He just didn’t want to go to the hospital for a third time,” said Gerald O’Collins, a professor of theology at Gregorian University in Rome. “What would have happened if he had gone back? Aggressive treatment that might have kept him alive a few more weeks, but there’s no moral obligation to accept this.”

A Surprising Statement

Nonetheless, the pope himself appeared to complicate the issue last year when he declared that the feeding and hydration of critically ill patients was in fact a moral obligation. He said that such treatment constituted a “natural act” for patients such as Schiavo who were in vegetative states or comas.

As the church struggles to keep its ethical teaching apace with strides in medical technology, the pope’s statement surprised some theologians. They read it as a sign the church was moving toward an endorsement of extraordinary measures as opposed to previous doctrine stipulating a lesser threshold of reasonable efforts to save the lives of the severely ill. Indeed, Schiavo’s parents, seeking to reinsert her feeding tube, cited the pope’s views in legal papers.

Other Christian ethicists said the concept did not apply to cases like the pope’s in which organs were shutting down and death was imminent.

“After all of the controversy that surrounded the Terri Schiavo death, some people might get the impression that according to Catholic teaching you hold on to life no matter what to the last possible moment,” said Father Thomas Reese, a New York-based theologian and editor of the Jesuit magazine America. “But ... if you are dying, you don’t have to take every medical procedure to prolong your life another day, another month. At some point you can accept that you are dying as God’s will and return to the Father.”

In the Schiavo case, the courts accepted her husband’s position that she would not have wanted to live in the state she was in. Vatican experts say that in the case of the pope, he was able to make a conscious decision to embrace his suffering, and also to “serenely abandon himself to God’s will,” in the words of a cardinal who stood in for him at a Vatican ceremony on Holy Thursday.

“Schiavo’s case and the pope’s case were taking place around Easter when the whole world was watching the themes of pain and death,” said the Rev. John P. Wauck, a Vatican expert at Rome’s Pontifical University of the Holy Cross. “The liturgical calendar provided a lens onto the suffering of Schiavo and the pope and a way to look at the suffering in a Christian perspective. In Schiavo’s case what was intended was that a living person die. In the pope’s case it was how death would come to him.”

Hospital Treatment

A long decline in the pope’s health accelerated Feb. 1 when breathing problems arising from a bad flu landed him at Gemelli hospital, nicknamed Vatican II because of his many stays there over the years.

Nonetheless, the pope resisted going to the hospital, said Marco Politi, a veteran Vatican correspondent for La Repubblica newspaper. Politi said in an interview Sunday that John Paul had told an aide: “No, no, no. I don’t want to go to the Gemelli.”

The hospital let him go home after 10 days, but he was rushed back Feb. 24 when doctors performed the operation to deal with his renewed breathing difficulties. Soon after his release on March 13, the pope made it clear to his medical team and his aides that he did not intend to be hospitalized again, according to Hejmo.

Although one of his doctors described his papal apartment as well equipped, it lacked the comprehensive technology of a hospital.

Wednesday, the day of his final public appearance -- an excruciating four minutes during which an emaciated pontiff struggled in vain to pronounce a blessing to a crowd in St. Peter’s Square -- Vatican officials announced that a feeding tube had been inserted in his nose. The move was a response to his increasing weakness and weight loss.

The nasal tube was the only option available for maintaining his nutrition without a return to the hospital, said Corrado Manni, one of the pope’s doctors, in an interview with the Polish TVP television network. It was also a painful procedure, and one that the pope found degrading, said Vatican correspondent Politi.

About this time, doctors at Gemelli asked papal aides whether the pope wanted to be brought there to be fed through a device that would be inserted into his stomach, Politi said.

“Dziwisz asked what would happen to him at the hospital,” said Politi. “The doctors replied that he would be hooked up to machines, but that would not change the general situation of his health. But the pope did not want to lie in a bed surrounded by tubes and machines. Dziwisz and Buzzonetti respected the pope’s decision.”

The pope’s condition worsened rapidly, a decline charted by a series of terse medical bulletins from the Vatican on Thursday and Friday. They described shallow breathing, cardiac failure and a patient drifting in and out of consciousness. Members of the church hierarchy began a round of farewell visits, their statements alerting the world’s 1 billion Roman Catholics that he was on the verge of death.

At Pontiff’s Bedside

Details about the final hours are sketchy because of the Vatican’s centuries-old tradition of secrecy. Cardinal Edmund Casimir Szoka, the governor of Vatican City, provided a glimpse of the scene at the pope’s bedside when he described his visit Friday to the papal apartment.

“The pope was completely conscious and completely alert,” Szoka said during an interview with CNN. “He couldn’t speak, but when he saw me, he nodded his head, he recognized me and tried to greet me. I kneeled by his side and told him in Polish that I had said Mass for him and that I was praying for him. There were three doctors on one side....

“When I left, I’m a priest so I automatically blessed him, and he blessed himself. It was very moving.... It was sad for me to see [what] must have been terrible suffering for him to have to keep gasping for breath.”

On Saturday, only his closest aides and friends, along with a medical team, participated in the vigil around the pope’s bed, according to an account on Polish television.

The churchmen included his two secretaries, Dziwisz and Father Mieczyslaw Mokrzycki, as well as Cardinal Marian Jaworski, Archbishop Stanislaw Rylko and Father Tadeusz Styczen. There were also four Polish nuns who had attended John Paul during most of his papacy. The three doctors were Buzzonetti, Alessandro Barelli and Ciro D’Allol. Two male nurses assisted them.

The clergymen at his bedside began the pope’s last Mass about 8 p.m. Outside in St. Peter’s Square, thousands of worshipers had gathered for a rosary service in his honor. They could see the lights on in the pope’s apartment. It is likely that he could hear their prayers.

Among the pope’s final words, according to Vatican spokesman Joaquin Navarro-Valls, was a reference to the crowd below his window, especially the young people with whom he had always felt a special bond.

Near the end, the pope slipped in and out of consciousness. He was gaunt, unable to speak, his breathing labored, his kidneys and heart shutting down. But he had fulfilled his wish that the final chapter of his life present public suffering as an affirmation of human dignity.

He had remained in control.

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Times staff writers Richard Boudreaux, Laura King, Larry Stammer, Maria De Cristofaro and Janet Stobart in Rome and staff writer John Daniszewski and special correspondent Ela Kasprzycka in Krakow, Poland, contributed to this report.