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: Historical clarity and today’s Catholic contentions

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One of the curiosities of the 21st-century Catholic debate is that many Catholic traditionalists (especially integralists) and a high percentage of Catholic progressives make the same mistake in analyzing the cause of today’s contentions within the Church — or to vary the old fallacy taught in Logic 101, they think in terms of post Concilium ergo propter Concilium [everything that’s happened after the Council has happened because of the Council]. And inside that fallacy is a common misreading of modern Catholic history. The traditionalists insist that everything was fine before the Council (which many of them therefore regard as a terrible mistake); the progressives agree that the pre-Vatican II Church was a stable institution but deplore that stability as rigidity and desiccation.

But that’s not the way things were pre-Vatican II, as I explain at some length and with some engaging stories in my new book, The Irony of Modern Catholic History: How the Church Rediscovered Itself and Challenged the Modern World to Reform (Basic Books). And no one knew the truth about pre-Vatican II Catholicism better than the man who was elected pope during the Council and guided Vatican II through its last three sessions, St. Paul VI.

On January 25, 1959, Pope John XXIII, thought to be an elderly placeholder, stunned both the Church and the world by announcing his intention to summon the 21st ecumenical council. That night, Cardinal Giovanni Battista Montini (who would be known as Paul VI four and a half years later), called an old friend. An experienced churchman who had long served Pius XII as chief of staff, Montini saw storm clouds on the horizon: “This holy old boy,” he said of John XXIII, “doesn’t know what a hornet’s nest he’s stirring up.”

That shrewd observation turned out to be spot on –– and not simply because of the Council, but because of the bees and hornets that had been buzzing around the ecclesiastical nest for well over 100 years.

Contrary to both traditionalist and progressive misconceptions, Catholicism was not a placid institution, free of controversy and contention, prior to Vatican II. As I show in The Irony of Modern Catholic History, there was considerable intellectual ferment in the Church during the mid-19th century, involving great figures like the recently-canonized John Henry Newman, the German bishop Wilhelm Emmanuel von Ketteler (grandfather of modern Catholic social thought), and the Italian polymath Antonio Rosmini (praised by John Paul II in the 1999 encyclical, Faith and Reason, and beatified under Benedict XVI). That ferment accelerated during the 25 year pontificate of Leo XIII, who launched what I dub the “Leonine Revolution,” challenging the Church to engage the modern world with distinctively Catholic tools in order to convert the modern world and lay a firmer foundation for its aspirations.

American Catholicism, heavily focused on institution-building, was largely unaware of the sharp-edged controversies (and ecclesiastical elbow-throwing) that followed Leo XIII’s death in 1903. Those controversies, plus the civilization-shattering experience of two world wars in Europe, plus a rapid secularization process in Old Europe that began in the 19th century, set the stage for John XXIII’s epic opening address to Vatican II. There, the Pope explained what he envisioned Vatican II doing: gathering up the energies let loose by the Leonine Revolution and focusing them through the prism of an ecumenical council, which he hoped would be a Pentecostal experience energizing the Church with new evangelical zeal.

John XXIII understood that the Gospel proposal could only be made by speaking to the modern world in a vocabulary the modern world could hear. Finding the appropriate grammar and vocabulary for contemporary evangelization didn’t mean emptying Catholicism of its content or challenge, however. As the Pope insisted, the perennial truths of the faith were to be expressed with the “same meaning” and the “same judgment.” Vatican II, in other words, was to foster the development of doctrine, not the deconstruction of doctrine. And the point of that doctrinal development was to equip the Church for mission and evangelization, for the modern world would be converted by truth, not ambiguity or confusion.

Over the past six and a half years, it’s become abundantly clear that more than a few Catholics, some quite prominently placed, still don’t get this history. Nor do the more vociferous elements in the Catholic blogosphere. Which is why I hope The Irony of Modern Catholic History helps facilitate a more thoughtful debate on the Catholic present and future, through a better understanding of the Catholic past.