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 Colorado places named after Catholic saints

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On Aug. 1, Colorado will have made it way over the hill at a ripe 144 years old. Better known as Colorado Day, the day commemorates the founding of our great Centennial State in 1876.

The Catholic Church has a rich history in Colorado, and believe it or not, various regions, geographic landmarks and places in the state are named after Catholic saints. The San Juan Mountain Range, the San Miguel River and the San Luis Valley are but a few examples.

In honor of Colorado Day, here are five places within “Colorful Colorado” that take their namesake from a Catholic saint. You probably already know a couple of them, but the other three are real “diamonds in the rough” that are worth making the trek; in fact, two of them were built and founded before Colorado was even Colorado.

Mother Cabrini Shrine, Golden, CO

 

One of Colorado’s most popular pilgrimage sites, it’s hard not to be enamored by Mother Cabrini Shrine. Originally founded as a girls’ summer camp by St. Frances Cabrini in 1910, the shrine overlooks the I-70 corridor heading into the mountains and is as charming as it is relaxing. In addition to the praying in the chapel, visitors can stay in the old Stone House that was built in 1914 or one of the various retreat houses that have been added over the years. Aside from being a wonderful space to pray, Mother Cabrini Shrine doubles as a sort of natural Stairmaster to get those steps in with the 373-step staircase leading up to the shrine, affectionately known as the Stairway of Prayer.

St. Catherine of Siena Chapel, Allenspark, CO

Photo by Andrew Wright

Better known as the Chapel on the Rock, this functioning Catholic chapel is perhaps one of Colorado’s most iconic landmarks. As the story goes, in the early 20th century, a man by the name of William McPhee owned the land where the chapel stands, known as Camp St. Malo. McPhee was a parishioner of the Cathedral in Denver, and he often allowed the parish to take kids hiking and camping on his property. During one of those trips, several campers saw a meteorite or shooting star that had appeared to hit the earth. They went looking for it and came upon the Rock that now stands as the foundation of St. Catherine of Siena Chapel. Completed in 1936, the chapel’s official namesake is fitting, as both it and St. Catherine of Siena share a common thread of mystical experiences facilitated by the Lord. It has had many visitors over the years, but perhaps none so famous as St. John Paul II who, ever the outdoorsman, just had to make a stop while in Denver for World Youth Day in 1993.

Abbey of St. Walburga, Virginia Dale, CO

 

Photo courtesy of the Abbey of St. Walburga

Located in the picturesque Virginia Dale, a small community just south of the Wyoming border, the Abbey of St. Walburga is a place where the voice of the Lord lives in the mountains, plains and rivers surrounding it. Named for the patroness of the Benedictine nuns, the abbey was founded in 1935 when three sisters from the Abbey of St. Walburg in Eichstätt, Bavaria were sent to a remote farm in what was Boulder. There, they built a strong foundation for the future of the abbey through hard work, poverty and an immovable trust in God’s providence. Today, the Benedictine nuns of Walburga humbly carry out the good works of the Benedictine order and carry on the legacy started nearly a millennium ago in 1035, when the original Walburg abbey in Eichstätt was founded.

San Luis, CO

Photo by Jeremy Elliot

Moving into the southern most regions of the State of Colorado, the Catholic roots of the region become much more evident. The oldest town in Colorado, San Luis, was founded in 1851 on the Feast of St. Louis, and predates the official founding of Colorado as a state by 25 years. The town is located along the Sangre de Cristo mountain range, which translates to “Blood of Christ.” One of the main attractions of the small town of just over 600 is a shrine at the town’s local Catholic parish. The Shrine of the Stations of the Cross was built by the parishioners of Sangre de Cristo Parish and the beautiful stations were designed and sculpted by native San Luis sculptor Huberto Maesta.

Capilla de Viejo San Acacio, Costilla County, CO

Photo from Wikicommons

Just to the west of the town of San Luis lies one of Colorado’s oldest gems. The Chapel of Old St. Acacius, or Capilla de Viejo San Acacio as it’s known to the locals, is the oldest non-Native American religious site in Colorado that’s still active today. While the building of the church cannot be dated precisely, it was likely completed sometime in the 1860s. The namesake of the church comes from St. Acacius of Byzantium, a third century martyr. Near the church is the small village of San Acacio, which a local tradition holds got its name after one of the earliest San Luis Valley settlements, originally called Culebra Abajo, was attacked by a band of Ute in 1853. As the Ute attackers approached, the villagers asked for the intercession of St Acacius, a popular saint among their people. The Ute suddenly halted and fled before they reached the town, scared off by a vision of well-armed warriors defending it. In gratitude for this salvation, the village was renamed San Acacio, and the villagers built a mission church in honor of the saint.