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When his life ended Saturday, John Paul II serenely accepted it on his terms, according to Vatican insiders.

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 prolonged his life.

Just before the end, the pope's longtime secretary offered a 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 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.

Antibiotics, respirator

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 to the recent ethical and theological battles over the Terri Schiavo case, though churchmen and theologians said 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 an 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 Serra newspaper.

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

The pope, assisted closely by Archbishop Stanislaw Dziwisz, his longtime secretary, played the central role in the decision-making, the doctor said.

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.

"No moral obligation"

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."

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 such as 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 onto life no matter what to the last possible moment," said the Rev. 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."

Final affirmation

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

"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."

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 clergymen at his bedside began the pope's last Mass about 8 p.m. Outside, in St. Peter's Square, thousands of worshippers 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, the pope made reference to the crowd below his window, especially the young people with whom he had always felt a special bond.

Near the final moment, 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.

There are some reports that at the very end, the pope, gazing out the window, whispered simply, "Amen."

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