A new form of advance directive for medical decisions is getting more attention around the country, including here in Nebraska. The document is called POLST which stands for Physician Orders for Life-Sustaining Treatments. It is a type of advance directive that consolidates, on a single form, preferences for life-sustaining treatments purportedly at the end of one’s life.
A typical POLST form provides predetermined options for patients to indicate whether they wish to refuse or request the following life-sustaining measures: cardiopulmonary resuscitation (CPR), medical interventions (full or limited treatment versus comfort care only), tube feeding, and antibiotics.
A significant distinction between POLST and other advance medical directives is that it includes a physician’s signature making it an immediately actionable medical order which mandates compliance by healthcare providers, including emergency responders.
Proponents say that POLST is needed because advance directives (AD) are failing to help patients retain control over end-of-life treatment. They cite the following failures:
1. Most people do not complete an AD and when they do they don’t understand the forms and the implications of their decisions.
2. Patients’ goals and preferences for care may change but ADs are rarely revisited. 3. Proxy decision makers often do not understand the patients’ wishes. 4. ADs are frequently unavailable when needed, health care providers may not know about AD or may not think they apply to patient’s situation. 5. AD language is often too vague to provide helpful guidance. [Religion and Cultures of East and West: Perspectives on Bioethics, Spring 2008]
Although I would agree that many of these failures do exist, they could and should be addressed rather than circumvented with a new and morally problematic document.
As the Catholic Bishops of Wisconsin stated very succinctly in their pastoral statement on POLST, “In general, the primary concern about POLST is that it presents options for treatments as if they are morally neutral when they are not neutral. Because we cannot predict the future, it is difficult to determine in advance whether specific medical treatments will be morally required or morally optional.
“These decisions depend upon factors such as the benefits, expected outcomes, and the risks or burdens of the treatment. A POLST oversimplifies these decisions and bears the real risk that an indication may be made on it to withhold a treatment that, in particular circumstances, might be an act of euthanasia. Despite the possible benefits of these documents, this risk is too grave to be acceptable.”
In an essay in the October 2014 issue of Ethics and Medics (a publication of the National Catholic Bioethics Center), Deacon Daniel Gannon, an attorney and ethicist in the Diocese of LaCrosse, WI, points specific concerns at that fact that POLST allows a “point in time… refusal of antibiotics, IV fluids, ventilators, and assisted nutrition and hydration.”
“The morality of refusing any of these treatments,” Deacon Gannon says, “is intrinsically connected to the pathologies and circumstances of the present moment; therefore, allowing their prior refusal is rightly characterized as in principle contrary to Catholic moral teaching.”
No advance directive (including the POLST) can assure that a person’s wishes at end of life are followed with exact precision. However, the advance directive known as the healthcare power of attorney (HCPOA) seems to be the best instrument for ensuring that one’s wishes are fully informed and one’s beliefs—as well as Catholic moral principles—are honored at the end of one’s life.
The HCPOA provides an opportunity to appoint a trusted person to make future health-care decisions in the event one would become incapable of making his or her own decisions. Of course, to maximize the HCPOAs effectiveness, we must thoroughly communicate with our proxy about our wishes and Catholic moral principles. And we must ensure that our entire family, our physician and local hospital(s) have a record of our HCPOA.
Sample HCPOA directives that reflect Catholic teaching and Nebraska law are available from the Nebraska Catholic Conference.
