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: For Love of Country: A Catholic Patriotism

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Our country has been through a lot this last year, as we all know. As many people have reacted against the founding and history of the United States, I have found myself drawn towards greater patriotism. By this, I simply mean a deeper appreciation of what I’ve been given by my country and also a growing realization of the duty I have to work for the common good, here and now. The Catechism of the Catholic Church speaks of this duty under the fourth commandment that enjoins honor not only to parents but also to anyone in authority.   

It is the duty of citizens to contribute along with the civil authorities to the good of society in a spirit of truth, justice, solidarity, and freedom. The love and service of one’s country follow from the duty of gratitude and belong to the order of charity. Submission to legitimate authorities and service of the common good require citizens to fulfill their roles in the life of the political community (2239). 

Catholics, and all people of good will, are called to a love and service of country in order to work for the common good.  

Eric Metaxas argues that the future of our country depends precisely upon the active role of Christians in his book, If You Can Keep It: The Forgotten Promise of American Liberty (Penguin, 2017). He describes something called the Golden Triangle, an idea he borrowed from Os Guinness, but which ultimately comes from the Founding Fathers. “The Golden Triangle of Freedom is, when reduced to its most basic form, that freedom requires virtue; virtue requires faith; and faith requires freedom. The three go round and round, supporting one another ad infinitum. If any one of the three legs of the triangle is removed, the whole structure ceases to exist” (54). John Adams, for example, related very clearly, “Our Constitution was made only for a moral and religious people. It is wholly inadequate to the government of any other” (quoted on 61). Metaxas comments, looking to specific examples around the world, “if you take God and faith and morality out of the equation, everything inevitably falls apart. It cannot be otherwise” (48). It cannot be otherwise. That may sound extreme, but we have many examples from Communist and Fascist countries and now even from movements within our country that aggressive secularism parallels a collapse of real freedom.  

The Constitution established an ordered liberty that requires responsibility and a determined effort of preservation. Hence the title of the book, taken from Benjamin Franklin, a republic “if you can keep it.” We are called to actively preserve our country: entering into a deeper understanding of the “idea” of America that undergirds the Republic as well as showing a loving determination to overcome challenges and threats to its continuance. This is not to whitewash the past, as we all know the injustices of our history. Metaxas argues that we can be grateful for the good and unique blessings of our heritage while also working to overcome failures. “To truly love America, one must somehow see both sides simultaneously” (226). Furthermore, by loving our country we are willing her good, drawing our own selves into the work for her good and helping her to be true to herself. “So that in loving America we are embodying her original intentions — we are indeed being America at her best — and in doing so we are calling her to her best, to be focused on doing all she can to fulfill the great promise which God has called her in bringing her into existence and shepherding her through trials and tribulations all these and centuries — and now” (235).  

As Catholics, we have a lot to offer our country by drawing from our rich intellectual and spiritual heritage. Michael Krom, a philosopher at St. Vincent College, provides us with a great resource in his new book, Justice and Charity: An Introduction to Aquinas’s Moral, Economic, and Political Thought (Baker, 2020). In an age of confusion, Catholics can bring greater clarity in our national discourse on the nature of human life, virtue, and politics. “We live in a time of ideological conflicts, in which the citizens of the nations of the modern world seem incapable of agreeing upon even the most basic of moral, economic, or political principles. Civil discourse has been replaced with violent protest, and reasoned dialogue with character assassination” (2). As Catholics, we should be able to look above all of this, literally: “While the Church does not force us to reject political citizenship, she demands that we direct it to the heavenly, and we can do that by heeding her call to engage the world rather than conform to it. I wrote this book out of the conviction that those who want to heed the Church’s call to engage our culture need to look to the past” (ibid.).  

Dr. Krom shows us that St. Thomas Aquinas has much to teach us about living the good life, in pursuit of a genuine freedom and happiness, and that this should inform a Catholic approach to economics and politics. It is hard to work for virtue if you don’t know what virtue really is, and difficult to act justly toward others if you don’t understand the nature of duty. Aquinas can help us to judge the direction of our country, as “a government cannot be called ‘good’ unless it promotes just moral and economic relationships between its citizens” (121). This is precisely the purpose of government — to promote right order and peace. We can’t just dispense with politics because, “the fact that humans find their fulfillment in political community means that situating their own good with the good of the community as a whole is central to happiness” (125). We are not isolated individuals and can’t attain a good and complete life on our own.  

Our ultimate good, however, is God, not the political life. Everything — all of our choices, including economic and political ones — must be directed to our ultimate goal. There are not “two ends to human existence, the earthly and the heavenly … [T]here is only one end, the beatific vision” (162). In this way the Church informs our citizenship. Krom explains “how inadequate this human law is as a teacher in the virtues, for it is limited in scope to the prevention of those vices from which even the wicked can refrain, and thus leaves those who seek after perfect virtue to their own devices … [H]uman law is in need of a higher law to truly bring about a just community” (155). Unfortunately, we’re seeing that our society is no longer even trying to prevent serious vice. Catholics and all believers have an important role to play, because “the lack of religion in the citizenry leads it down the path of totalitarianism. It Is absolutely critical that a people maintain a strong commitment to a transcendent measure of the common good in order to protect the true flourishing of its members” (171). Krom’s important work on justice and charity can teach us how a Catholic can exercise a proper patriotism, a true love of country.