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: Five tips for reading the Word of God

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Sunday, Jan. 24 marks “The Sunday of the Word of God,” instituted by Pope Francis last year and to be held every year on the third Sunday of Ordinary Time. This may strike us as odd, as we might think to ourselves, “but isn’t the Bible read at every Sunday Mass?” Certainly so. Not only that, but every daily celebration of the Mass proclaims the Word of God.

What’s different about “The Sunday of the Word of God,” however, is that it’s not just about hearing the Bible read on Sundays. As the Congregation for the Doctrine of the Faith notes, it “reminds us, pastors and faithful alike, of the importance and value of Sacred Scripture for the Christian life, as well as the relationship between the word of God and the liturgy: ‘As Christians, we are one people, making our pilgrim way through history, sustained by the Lord, present in our midst, who speaks to us and nourishes us. A day devoted to the Bible should not be seen as a yearly event but rather a year-long event, for we urgently need to grow in our knowledge and love of the Scriptures and of the Risen Lord, who continues to speak his word and to break bread in the community of believers. For this reason, we need to develop a closer relationship with Sacred Scripture; otherwise, our hearts will remain cold and our eyes shut, inflicted as we are by so many forms of blindness.’” This gives us a wonderful opportunity to pause and reflect on the Sacred Scriptures. 

There are two means by which God Divinely reveals truths to us: Sacred Scripture and Sacred Tradition. As such, the Bible is not merely a human document, nor simply a collection of amazing stories that call us to do heroic things, or a collection of wise sayings. Rather, the Scriptures are “inspired.” St. Paul has a beautiful teaching about this in 2 Timothy 3:16-17 – “All scripture, inspired of God, is profitable to teach, to reprove, to correct, to instruct in justice, That the man of God may be perfect, furnished to every good work.” By “inspired” we mean that God is the principle author of the Bible.

Certainly there were different men who physically wrote the words on the papyrus. Yet these men were influenced by the grace of inspiration to write, not just their own words, but God’s. And so the Scriptures are a mysterious congruence of Divine and human authorship – the human writers capably made full use of language, literary forms, creativity, and writing style to communicate their message, yet they did so under the grace of Divine inspiration. This means that while they wrote in such a way that they had full freedom to write as they wanted, what they wrote was also, “to a tee,” exactly as God wanted written. God is the principle author of the Bible, the human author its secondary writer. Such inspiration is how, despite the various human authors, events, and historical and cultural contexts behind the 73 Biblical texts, we’re still left with only one story since they all have the same one primary author. 

Given that the Bible is the written word of God, I’d like to offer a few “tips” for reading the Bible, since it certainly cannot be read like any other text. 

1. Pray! We must pray before opening the Scriptures for enlightenment from God. We must pray after reading in thanksgiving to God. And we must pray throughout reading in order to encounter God in Scripture and apply it to our life. Of course, the tried and trusted practice of praying the Scriptures is Lectio DivinaThe Ladder of Monks by Guigo II is the ancient resource for Lectio Divina, while a helpful book to get you started is Dr. Tim Gray’s Praying Scripture for a Change: An Introduction to Lectio Divina

2. Remember that you are in no rush. The important point is encountering Christ in the Scriptures, not racing through them. Speed reading isn’t reading, after all, much less when applied to the Word of God. It’s not about getting through the Bible, but encountering Christ therein. That may be a few chapters at a time or may actually be only one verse that you pray with. Whatever the case, slow and steady wins the race, as Aesop reminds us. 

3. We have to read the Scriptures regularly, daily if possible. We read in Psalm 1, “Blessed is the man who walks not in the counsel of the wicked, nor stands in the way of sinners, nor sits in the seat of scoffers; but his delight is in the law of the Lord, and on his law he meditates day and night.” Meditating day and night. A good way to start would be to read one Psalm a night as a part of your nightly prayer. Ever better would be praying that one Psalm with your spouse, if married. 

4. Do not worry about starting on page one and reading from cover to cover. It’s easy to get overwhelmed and lost in the text. We all know about Adam and Eve, Noah and the Flood, Moses and the Plagues. But how many understand animal sacrifices in the Book of Leviticus or its purity laws? It’s very easy, starting from page one and flipping straight through, to lose sight of the story of salvation history. Start from page one if you’d like, but don’t feel like you can’t start with whatever book (especially the Gospels) that you find yourself drawn to. 

5. Come take classes with the Denver Catholic Biblical School! In chapter eight of the Book of Acts, we read of an Ethiopian Eunuch reading from the Prophet Isaiah. When the Deacon Philip asks him if he understands what he’s reading, the Eunuch responds, “How can I, unless some one guides me?” This is what we at the Biblical School are here for – to guide you in your encounter with Christ in the Sacred Scriptures. We’re in the middle of our Scripture classes already for this year, but we always start new classes in the fall every September. And in the meantime, we have plenty of things still coming for this year – a class on Catholic Social Teaching that begins on Jan. 27 a lecture series for Lent that starts on March 1, a conference on the Sacred Heart being offered on May 15 and Aug. 28, and a six-week class on St. Joseph in the summer starting in July. We have something for everybody – just reach out to us!