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: Juan Carlos Reyes, Director of Centro San Juan Diego, has been called to the Father’s House

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A happy, hardworking man dedicated to evangelization and to Hispanic immigrants: With these words, friends and coworkers remember Juan Carlos Reyes, who passed away March 20 after fighting a grave illness over the previous two months. He was 33.

Juan Carlos was born in Michoacán, Mex., on Dec. 28, 1985. He arrived to the United States at a young age, completed his secondary studies and later a bachelor’s degree in religious sciences thanks to an agreement between the Anáhuac University in Mexico City and Centro San Juan Diego. He was also a student at the Denver Catholic Biblical School under the Lay Division of St. John Vianney Seminary.

As a teen, he joined a youth group at St. Anthony of Padua in Denver and attended Centro San Juan Diego for various classes and trainings for pastoral workers.

He began working at Centro San Juan Diego in 2012, was promoted to Director of the Family Services in 2015 and became director of the organization in March 2018. As director, he led important programs that sought care for immigrants and formation for pastoral workers. Juan Carlos was one of the initiators of the agreement between Centro San Juan Diego and Universidad Autónoma del Estado de Puebla (UPAEP) in Mexico, making it possible for many immigrants to obtain a bachelor’s degree in their native language valid in the United States.

“To talk about Centro San Juan Diego is, in a sense, to talk about my own life. I would not be here if it were not for Centro San Juan Diego’s support. I saw in CSJD an active Church that reached out to me,” Juan Carlos told the Denver Catholic in October 2018. He was also a delegate for the V National Encuentro in Grapevine, Texas, this past September.

Besides working for the Archdiocese, Juan Carlos conducted a ministry with his brother titled Agua y Sangre” (Blood and Water), in which they commented on the daily Mass readings via YouTube, reaching up to 100,000 views daily.

One of his closest friends was Alfonso Lara, Director of Hispanic Evangelization for the Archdiocese of Denver. “Many of us witnessed how Juan Carlos grew and matured as a man, as a Christian, as a Catholic, as a leader,” he said. “His potential, spirit and commitment were always attractive. I always admired his youthfulness, dedication and love for people. He emerged from the Hispanic community and later served and poured out his heart to them.”

Luis Soto, Director of Parish Implementation and Hispanic Outreach for the Augustine Institute and former Director of Centro San Juan Diego, met Juan Carlos when he was 15 years old, and remembers him as a “dynamic, funny [young man] with many ideas and a great desire to serve. He was a member of a family that was committed to the faith. He was restless and had a great desire to learn in order to serve better. He would register for any program we started.”

Abram León, Lay Ecclesial Movement Specialist for the Archdiocese of Denver, remembers Juan Carlos as “a great human being” who “was proud to be a father.” Deacon Rubén Durán, the archdiocese’s Hispanic Family Ministry Specialist, also remembers him as “a man of God, of deep faith. He evangelized with words and actions.”

Juan Carlos was a loving husband to his wife of more than 10 years and a proud father of three sons.