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: The Vatican’s Choice: Jimmy Lai or Xi Jinping?

Sign up for a digital subscription to Denver Catholic!

In mid-May, Chinese leader Xi Jinping unveiled a plan to bypass Hong Kong’s legislature and impose draconian new “national security” laws on the former British colony. Putatively intended to defend Hong Kong from “secessionists,” “terrorists,” and “foreign influence,” these new measures are in fact designed to curb the brave men and women of Hong Kong’s vibrant pro-democracy movement, who have been aggravating the Beijing totalitarians for a long time. With the world distracted by the Wuhan virus (which the Chinese government’s clumsiness and prevarication did much to globalize), the ever-more-brutal Xi Jinping regime evidently thinks that this is the moment to crack down even harder on those in Hong Kong who cherish freedom and try to defend it.

This latest display of Beijing’s intent to enforce communist power in Hong Kong coincides with the most recent persecution of my friend, Jimmy Lai.

Jimmy and I have only met once. But I have long felt a kinship with this fellow-Catholic, a convert who first put his considerable wealth to work in support of important Catholic activities and who is now risking all in support of the pro-democracy movement in Kong Kong. Arrested in February, and then again in April, Jimmy Lai has been charged with helping organize and lead “unauthorized protests.” That he was in the front ranks of pro-democracy demonstrations is true. The question is, why do the Chinese communists regard peaceful protest in support of freedoms Beijing solemnly promised to protect as treasonous?

In late May, the thugs in Beijing tightened the ratchet of repression another notch: Jimmy Lai’s case was transferred to a court that could give the 72-year old a five-year sentence, or even consecutive sentences. But what else could be expected from a regime that was already trying to bankrupt Lai’s pro-democracy newspaper, Apple Daily, by pressuring both Chinese and international firms to stop buying advertising space there? Shamefully, far too many have kowtowed to those pressures, and a recent Wall Street Journal op-ed article reported that Apple Daily is now cut off from 65% of the Hong Kong advertising market. Meanwhile, Beijing, while trying to reassure the business community that everything will be just fine, warns business leaders (as well as diplomats and journalists) not to “join the anti-China forces in stigmatizing or demonizing” the new national security laws.

The Xi Jinping regime may be less stable than it wants the world to think it is. Secure regimes do not increase repression, as Beijing has done for several years now. Moreover, labeling all criticism of the Xi Jinping government as “anti-China” is not the play a regime confident about its legitimacy and stability would make. Such tactics seem clumsy; they bespeak sweaty nervousness, not calm self-assurance.

The attempt to break the Hong Kong democracy movement is one facet of a broader campaign of repression that has not spared Chinese religious communities on the mainland. One million Muslim Uyghurs remain penned in Xinjiang concentration camps, where they are being “educated.” Protestant house churches are under constant threat. And repressive measures continue to be taken against Catholics and their churches, despite the almost two-year old (and still secret) agreement between the Holy See and Beijing. That agreement, which gave the Chinese communist party a lead role in the nomination of bishops, looks ever more like one in which the Vatican gave away a great deal in return for hollow promises; Chinese Catholics who do not toe the party line as the Chinese communist party defines that line are still persecuted. The effects of this sorry affair on the Church’s evangelical mission in the China of the future – hopefully, a post-communist China – will not be positive.

Around the world, voices have been raised in support of Hong Kong’s brave pro-democracy demonstrators. Has the Holy See’s voice been heard? If so, I missed it and so did many others. Are strong representations in favor of religious freedom and other basic human rights being made by Vatican officials behind the scenes in Beijing and Rome? One might hope so. But if the Holy See’s current China policy is in fact a reprise of its failed Ostpolitik in central and eastern Europe during the 1970s, those representations are more likely tepid and wholly ineffectual.

With one of its most courageous Catholic sons now in the dock and facing what could be life-threatening imprisonment, the Vatican now faces a defining choice: Jimmy Lai or Xi Jinping?