Of proxies and POLSTs: The good and the bad in end-of-life planning

Fr. Tadeusz Pacholczyk

Planning for end-of-life situations is important. We should put in place an advance directive before our health takes a serious turn for the worse and we are no longer able to indicate our own wishes or make our own decisions. Advance directives can be of two types: living wills and health care agents.

The best approach is to choose a health care agent (a.k.a. a “proxy” or a “durable power of attorney for health care”). Our agent then makes decisions on our behalf when we become incapacitated. We should designate in writing who our health care proxy will be. The National Catholic Bioethics Center (www.ncbcenter.org) and many individual state Catholic conferences offer helpful forms that can be used to designate our proxy. Copies of our completed health care proxy designation forms should be shared with our proxy, our doctors, nurse practitioners, hospice personnel, family members and other relevant parties.

In addition to choosing a health care proxy, some individuals may also decide to write up a living will in which they state their wishes regarding end-of-life care. Living wills raise concerns, however, because these documents attempt to describe our wishes about various medical situations before those situations actually arise, and may end up limiting choices in unreasonable ways. Given the breathtaking pace of medical advances, a person’s decisions today about what care to receive or refuse may not make sense at a later timepoint. In the final analysis, it is impossible and unrealistic to try to cover every medical situation in a living will, and it is preferable to have a proxy, a person we trust, who can interact with the hospital and the health care team, weigh options in real time, and make appropriate decisions for us as we need it.

A new type of living will known as a “POLST” form — a tool for advance planning — also raises concerns. The POLST form (which stands for Physician Orders for Life Sustaining Treatment) is a document that establishes actionable medical orders for a patient’s healthcare. The form is typically filled out with the help of trained “facilitators” — usually not physicians — who ask questions about patients’ health care wishes, and check boxes on the form that correspond to their answers. The facilitators receive training that can lead them to paint a rather biased picture of treatment options for patients, emphasizing potential negative side effects while side-stepping potential benefits or positive outcomes.

POLST forms thus raise several significant moral concerns:

1. The approach encouraged by the use of POLST forms may end up skewed toward options of non-treatment and may encourage premature withdrawal of treatments from patients who can still benefit from them.

2. Filling out a POLST form may preclude a proxy from exercising his or her power to protect the rights of the patient, since the form sets in motion actual medical orders that a medical professional must follow. As a set of standing medical orders, the POLST approach is inflexible. Many POLST forms begin with language like this: “First follow these orders, then contact physician or health care provider.” Straightforwardly following orders created outside of a particular situation may be ill-advised, improper and even harmful to the patient.

3. In some states, the signature of the patient (or his or her proxy) is not required on the POLST. After the form has been filled out, it is typically forwarded to a physician (or in some states to a nurse practitioner or a physician’s assistant) who is expected to sign the form. Thus, in some states, a POLST form could conceivably be placed into a patient’s medical record without the patient’s knowledge or informed consent. In a recent article about POLST forms in the Journal of Palliative Medicine, approximately 95 percent of the POLST forms sampled from Wisconsin were not signed by patients or by their surrogates. Fortunately, in some other states like Louisiana, the patient’s signature or the signature of the proxy is mandatory for the form to go into effect.

The implementation of a POLST form can thus be used to manipulate patients when they are sick and vulnerable, and can even lead to mandated orders for non-treatment in a way that constitutes euthanasia. The POLST template represents a fundamentally flawed approach to end-of-life planning, relying at its core on potentially inappropriate medical orders and dubious approaches to obtaining patient consent.

Notwithstanding the pressure that may be brought to bear on a patient, no one is required to agree to the implementation of a POLST form. Patients are free to decline to answer POLST questions from a facilitator, and should not hesitate to let it be known that they instead plan to rely on their proxy for end-of-life decision making, and intend to discuss their healthcare options uniquely with their attending physician.

 

COMING UP: Read Archbishop Aquila’s letter in response to the Pennsylvania Grand Jury Report

Sign up for a digital subscription to Denver Catholic!

The following letter written by Archbishop Samuel J. Aquila in response to the Pennsylvania Grand Jury report was read at all weekend Masses Aug. 17-18.

18 August 2018

My dear Brothers and Sisters in Christ,

I write to you today with great sadness to respond to yet another scandal that has shaken the Church. Even though many of the details in the Grand Jury Report in Pennsylvania had already been reported, the full release was still undeniably shocking and its contents devasting to read. We face the undeniable fact that the Church has gone through a dark and shameful time, and while a clear majority of the Report addresses incidents occurring 20+ years in the past, we know that sin has a lasting impact and amends need to be made.

Many children have suffered from cruel behavior for which they bore no responsibility. I offer my apology for any way that the Church, its cardinals, bishops, priests, deacons, or laity have failed to live up to Jesus’ call to holiness. I especially offer this apology to the survivors, for the past abuses and for those who knowingly allowed the abuse to occur. I also apologize to the clergy who have been faithful and are deeply discouraged by these reports.

Everyone has the right to experience the natural feelings of grief as they react to this trauma – shock; denial; anger; bargaining; and depression. I want you to know I feel those emotions as well – especially anger. I believe the best way to recover is a return to God’s plan for human sexuality. In response to the Archbishop McCarrick revelations, I have written at length about the spiritual battle we are facing. That letter can be found on the archdiocese’s home page – archden.org.

I ask everyone to pray for the Church in Pennsylvania, though these dioceses over the last 20 years have greatly evolved from how they are described in the Grand Jury Report, the Church must face its past sins with great patience, responsibility, repentance and conversion.

Creating an environment where children are safe from abuse remains a top priority in the Archdiocese of Denver. In our archdiocese, we require background checks and Safe Environment Training for all priests, deacons, employees, and any volunteers who are around children. During this training, everyone is taught their role as a mandatory reporter, and what steps to follow if they witness or even suspect abuse. We also require instruction for children and young people, where they are taught about safe and appropriate boundaries, and to tell a trusted adult if they ever feel uncomfortable. We participate in regular independent audits of our practices, and we have been found in compliance every year since the national audit began in 2003.

Finally, while we have made strides to improve our Archdiocese, I am aware that the wounds of past transgressions remain. We are committed to helping victims of abuse and we are willing to meet with anyone who believes they have been mistreated.

I urge all of us to pray for holiness, for the virtues, and for a deeper relationship with Jesus Christ. Only he and he alone can heal us, forgive us, and bring us to the Father. Be assured of my prayers for all of you and most especially the victims of any type of sexual abuse committed by anyone.

Sincerely yours in Christ,
Archbishop Samuel J. Aquila