Physician Orders for Life-Sustaining Treatment
Vice President, Corporate Ethics, Daughters of Charity Health System
Lisa Gasbarre Black is General Counsel to Catholic Charities Health and Human Services in the Diocese of Cleveland. In the recent edition of Ethics and Medics published by the National Catholic Bioethics Center, Black is highly critical of Physician Orders for Life-Sustaining Treatment (POLST) that went into effect on January 1, 2009 in California (and at varied times in other States).
Black advises that POLST forms "should be used only with great care." Since POLST forms are commonly used in Catholic Health Care Institutions, we should be mindful of Black's hesitancies about their use.
Her major concern centers on her belief that "POLST theory seeks to elevate patient autonomy to the level of an enforceable, legal right." Black fears that POLST too easily translates a person's end-of-life medical wishes into "an immediately actionable medical order." She concludes, "...the POLST movement is a national effort to manage and control death under the guise of compassion."
Black makes several serious accusations against POLST: (1) its implementation has a "corrosive effect ... on Catholic moral teaching, (2) it attacks the sacredness of human life by hastening death, (3) it mandates absolute conformance with a person's end-of-life wishes, and (4) contradicts Catholic doctrine as exemplified in her selected citations from the Declaration on Euthanasia (Congregation for the Doctrine of the Faith, 1980), John Paul II's The Gospel of Life (1995), and the Ethical and Religious Directives for Catholic Health Care Services(United States Conference of Catholic Bishops, 2001, revised 2009).
Let's consider these points:
FIRST: The POLST "movement" began in 1991 in Oregon. It evolved from the belief that the practice of medicine had become overly paternalistic, resulting in disregard for a patient's end-of-life wishes. The object of POLST is to foster better communication between doctor and patient, and thus enhance the quality of care for people with advanced illness and frailty. The POLST form is designed for seriously ill patients and must be signed by the patient (or surrogate) and the patient's physician.
SECOND: POLST aims at articulating a patient's wishes regarding unwanted or medically ineffective treatments such as cardiopulmonary resuscitation (CPR), antibiotics and IV fluids, ventilators, and tube feeding. Signing a POLST form is completely voluntary and is designed for seriously ill persons in very poor health, regardless of their age.
THIRD: While an individual's physician must sign the POLST form, its completion might result from a conversation between a patient/surrogate and a health care professional, e.g., a nurse, social worker, or the doctor. POLST forms can be changed or amended as an individual's treatment preferences change in light of his or her medical condition.
FOURTH: The Ethical and Religious Directives for Catholic Health Care Services upholds the right of a person to "make an advance directive for their medical treatment" and a Catholic institution will honor this directive (sometimes named a Durable Power of Attorney for Health Care) as long as it is does not conflict with Catholic teaching (nos. 24 and 25).
FIFTH: An advance directive contrary to Catholic teaching would indicate a person's desire for physician-assisted suicide or euthanasia and thereby deny the dignity and sanctity of life and God's providential care for human life. This same principle would apply to a person's POLST form. It is of great importance for any individual filling out an advance directive or a POLST form to be guided by Catholic teachings on end-of-life care, e.g., A Catholic Guide to Critical End of Life Decisions, Daughters of Charity Health System, 2007, and A Catholic Guide to Advance Health Care Decisions, Catholic Health Association, 2006.
SIXTH: The use of an advance directive or a POLST form is not against Catholic doctrine or teaching as long as certain parameters are kept central: (1) A belief that God has created each of us for eternal life, and we are all a precious gift from God, made in God's image and likeness, (2) death is an inevitable part of life and has been redeemed by Christ, (3) an individual has the Catholic-recognized right to make medical treatment decisions based on the church's longstanding teaching on ordinary/proportionate and extraordinary/disproportionate medical care, (4) to the degree that a treatment prolongs life, cures, restores function, relieves symptoms, alleviates pain and engenders physical, psychological or spiritual well-being, to that degree a treatment is beneficial, (5) simply because a treatment is beneficial, it is not mandatory as its burdens might outweigh its benefits, and (6) a treatment is or becomes burdensome when it is financially costly, psychologically repugnant, unlikely to succeed, unlikely to provide great benefit, experimental or difficult to administer (see Smith and Kaczor, Life Issues, Medical Choices, 2007, chapter 5).
While Blacks concerns are to some degree understandable, and raise cautions about POLST forms (and logically advance directives), her worries should not be raised to a level that an informed use of POLST forms and advance directives is contrary to Catholic teaching or inimical to the Ethical and Religious Directives. Managing one's dying is in accord with Catholic moral principles as "the dying should be given attention and care to help them live their last moments in dignity and peace (Catechism of the Catholic Church, no. 2299).