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: Archbishop Aquila on ad limina visit, Pope Francis and more

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During his ad limina visit Feb. 10-15, Archbishop Samuel J. Aquila was granted an audience with Pope Francis for over two hours where they discussed several topics pertinent to the Church today.

Archbishop Aquila was among a contingent of U.S. bishops representing Region XIII in the United States, which includes the states of Colorado, New Mexico, Arizona, Wyoming and Utah. He along with the bishops of those states met with the Holy Father Feb. 10. With the release of Querida Amazonia scheduled just a few days later on Feb. 12, Pope Francis discussed the document produced from last year’s Amazon Synod with the bishops.

“He brought up the question of celibacy, and he said [his] primary concern is that Gospel be proclaimed in the Amazon and that all of us need to focus on Jesus Christ and the proclamation of the Gospel first,” Archbishop Aquila said in an interview with EWTN. “If they proclaim the Gospel and are faithful to the Gospel, then vocations will come forth.”

Archbishop Aquila with Pope Francis during his ad limina visit Feb. 10. (Photo: Servizio Fotografico Vaticano)

With much discussion surrounding the Amazon Synod and possible implications it would have for the universal Church, Archbishop Aquila was reassured by the Pope’s comments on synodality and the Church’s application of it.

“Even in the understanding of synodality, which we spoke about, it always has to be ‘under Peter and with Peter’ and that synods cannot be going off and creating things that they want done,” the archbishop said. “He made it very clear: that is not synodality in the Catholic understanding. That was very reassuring.”

Among the other topics the bishops discussed with the Holy Father were some of the challenges faced by the Church in the United States and how to address them.

“The Holy Father was very clear: He said transgenderism is one of the great challenges in the United States right now, and the other is abortion,” Archbishop Aquila said. “Both of them really deal with the dignity of human life and the understanding of human life and do we truly receive from God the gender that he has given to us.

Bishop Jorge H. Rodriguez with Pope Francis during his ad limina visit Feb. 10. (Photo: Servizio Fotografico Vaticano)

“There are only two genders, male and female, and so how do we open our hearts to receiving that as gift.”
Archbishop Aquila said that they Holy Father also “spoke of media, and how the far left goes after him and the far right goes after him, and neither one really presents who he is.”

In a time where Pope Francis’ comments can be rather polarizing and even mischaracterized, Archbishop Aquila was struck by the depth of the Holy Father’s faith in his audience with him.

“[The Pope] has a very, very deep faith. He is convinced of the Gospel, he is totally convinced of Jesus Christ, he is convinced that there are teachings in the Church that can never change and that we have to be faithful to the Church.”

Hannah Brockhaus of Catholic News Agency contributed to this report.

Featured image by Paul Haring/CNS