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

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: Sin, suicide and the perfect mercy of God

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I love my hair stylist. 

She’s a devoted Christian. So, when I see her, we tend to have much deeper discussions than the usual gossipy hair stylist sessions. And, because it’s a small shop, the discussions often branch out to the other people within earshot, waiting for their appointments or waiting for their color to process. Because she tends to attract a smart and faithful clientele, the discussion is always interesting. 

Yesterday, at my bimonthly appointment, we somehow got onto the topic of suicide — specifically, the insidious way that it spreads among teenagers. One suicide often leads to another, which leads to another. I made the comment “It is demonic.” 

At that point, a woman in the waiting area chimed in. “I disagree. I’m Catholic. It used to be a mortal sin, but they changed it. It’s not any more. It’s mental illness.” 

If a nice Catholic lady at my hair salon could be confused about this, I figured perhaps some of you out there may be as well. Which made me think perhaps it’s time for a little review on the nature of sin — both in general, and specifically as it applies to suicide. 

First, sin in general. The fundamental point here is that the Catholic Church has no power to decide what is a sin and what isn’t. It’s not like there’s a committee that meets periodically to review the list of sins, and decide if any need to be promoted from venial to mortal, or demoted from mortal to venial, or dropped from the list entirely. 

Sins are sins because they are outside of God’s will. And they are outside of God’s will because they have the potential to do tremendous damage to people created in His image and likeness, whom He loves. We know they are sins because it was revealed to us in Scripture, or it has been handed down from the time of Christ in sacred tradition. Sometimes the Church must apply these timeless, God-given principles to new situations, to determine the morality of technologies undreamt of in ancient times. 

The Church has the authority to do that because she received it from Christ, her bridegroom. And once she does declare on a subject, we believe it is done through the inspiration of the Holy Spirit, who is the same yesterday, today and tomorrow. So the Church isn’t going to change her mind. Something can’t be a sin, and then suddenly NOT be a sin. 

“But,” you ask. “What about eating meat on Friday? That was a sin, and now it isn’t.” This is an example of a discipline of the Church. Eating meat has never, in itself, been an objectively sinful behavior — on Fridays or any other day. But the Church was calling us, as Jesus calls us, to do penance. And the Church selected that penance as something we could all, as a Church, do together. The sin was never in the ingestion of the meat. It was in disobeying the Church in this matter. This particular discipline has been dropped. But it doesn’t change our obligation to in some way do penance for our sins and the sins of the world. 

Now, on to suicide. It is obvious that something must have changed in the teachings of the Church. Because, in the olden days, a person who committed suicide couldn’t be buried with a Catholic funeral Mass. And now they can. So what gives? 

Here’s the situation. Taking innocent human life is always a grave evil. (I add the “innocent” qualifier to distinguish this discussion from one about self defense, or about the death penalty — which in a sense is self defense. But those are separate discussions.) God is the author of life, and it is He who decides when our lives will end. To usurp that power always has been, and always will be, a grave moral evil. 

But there is an important distinction we must understand. There is the objective gravity of the sin — the nature of it, and the great damage done by it. Then there is the question of the individual’s moral culpability of that sin. In other words: a great evil was done. But is the person who did it liable to judgment for it? Or were there extenuating circumstances that mean that, while the evil was indeed done, the person who did it was somehow functioning in a diminished capacity that reduces or eliminates their moral responsibility? 

For a person to be culpable for a mortal sin, three conditions must be met. First, the objective act must be gravely sinful. Second and third, the person committing the sin must do so with full knowledge of the sinfulness of the act, and full consent of the will. In the question of suicide, we have learned to much about the psychological condition of a person driven to such a horrible deed. The instinct to self preservation is strong. In order to overcome it, the mental and/or physical suffering is frequently very intense. There may even be, as my friend at the salon mentioned, mental illness involved. All of this can drastically reduce a person’s mental and intellectual capacity to make rational decisions. 

And so, while an objectively horrifying act has occurred, God may very well have tremendous mercy on that person’s soul, given the extreme states of agitation and pain that led up to the act. 

Know that I write all of this as someone who has lost one beloved relative and several friends to suicide. And I am tremendously optimistic in my hope that they are with God. Not because they didn’t do something terrible, or that what they did was somehow justified. But because the God who loves them sees their hearts, and knows that pain and suffering can drive people to acts they wouldn’t possibly consider while in their “right” minds. 

And this is why the Church offers the Rite of Christian Burial to those who die by suicide. Because they need the prayers. And their families need the comfort. And because the Church, too, believes in that the God who embodies perfect justice also embodies perfect mercy. 

And we live in great hope that they are with Him.