Our Lives on a Bright-Colored Form A Statement on the Physician Orders for Life-Sustaining Treatment (POLST) Paradigm in the State of Wisconsin By Rev. Javier I. Bustos 1 September 8, 2011 The Physician Orders for Life-Sustaining Treatment (POLST) 2 Paradigm Initiative began in Oregon in 1991. Some experts argued that patient wishes for life-sustaining treatments were not being honored consistently despite the availability of advance directives. The Center for Ethics in Health Care at Oregon Health & Science University convened representatives from stakeholder healthcare organizations to develop the Medical Treatment Coversheet. 3 In 1995 the POLST form was released for use in Oregon. Currently, the proponents of this paradigm report over one million forms distributed in that state alone. The initiative was shortly extended to New York, Pennsylvania, Washington, West Virginia, and Wisconsin. POLST is currently present in more than 30 states. The POLST paradigm was designed to ensure that the patient treatment preferences are honored throughout the healthcare system. 4 As a main tool, this paradigm takes the shape of a bright-colored form, in which a person expresses his or her wishes regarding life-sustaining treatment, such as Cardiopulmonary Resuscitation (CPR), medical interventions when the individual has pulse and/or breathing, use of antibiotics, and artificially administered nutrition and hydration. By having the patient, parent of a minor, or a guardian and a physician sign the POLST form, the patient s (the parent s or the guardian s) wishes are converted into medical orders that are transferable throughout the healthcare system. 5 POLST is not an advance directive; that is, a Living Will or a Healthcare Power of Attorney. Advance directives are accepted nationally; not all states accept POLST. A major difference between advance directives and POLST is that the first is not signed by a physician, and consequently it does not have the medical authority that POLST has. The indications expressed on the POLST form must be honored by all medical personnel. The POLST form usually summarizes an individual s advance directives, and makes them available immediately throughout the healthcare system. Even though each state has unique ways of administering the use of this form, the implementation of a POLST program must include the training of facilitators on how to conduct a POLST conversation. POLST-trained facilitators are often social workers or nurses responsible for developing plans of care for residents of long-term care facilities, home health, or hospice. 6 In Wisconsin, POLST is a voluntary procedure. It is not mandated nor prohibited by a state law. Hospitals, nursing homes, and hospice facilities may or may not choose to develop and sponsor a POLST program. What is at stake on the POLST form is God s gift of human life. That is why, the Archdiocesan Healthcare and Bioethics Committee of the Archdiocese of Milwaukee (AHBC) has carefully reflected on the way POLST cares and treats human life and dignity. The AHBC recognizes that in the state of Wisconsin the POLST form and paradigm presents significant redflags that overshadow the potential positive aspects of this tool. Supporters of POLST highlight that through this form patient s wishes are respected, plan treatment flows consistently throughout the healthcare system, and crucial decisions on life-sustaining treatments are made handy in a timely
Our Lives on a Bright-Colored Form 2 manner. Even though these are desirable goals, the POLST paradigm in Wisconsin strives to accomplish these and other goals in a highly questionable and misleading way. The AHBC has identified the following concerns: In preparation for death, the Church does not oppose the use of advance directives; however, the USCCB clearly stated that a Catholic healthcare institution will not honor an advance directive that is contrary to Catholic teaching. If the advance directive conflicts with Catholic teaching, an explanation should be provided as to why the directive cannot be honored. 7 This statement is also true for new forms of patient report of preferences for life-sustaining treatment, such as POLST. The conscience of Catholic healthcare providers should not be violated by imposing specific actions contrary to their faith. POLST s aim in providing a venue of preparing for death is a good thing. The Church encourages all to prepare for physical death. Healthcare providers are essential in this preparation. 8 However, besides the medical preparation for death, the Church also emphasizes the necessary spiritual and emotional preparation for it. 9 POLST offers the opportunity of preparing for death from the medical point of view. Such a preparation is incomplete if one does not include the spiritual and emotional preparation for death. Healthcare Power of Attorney, Living Will, and forms like POLST need to be seen as instruments that honor the gift of life, not as tools that speed the process of death. Life is a gift from God; we do not own it. Consequently, no one can arbitrarily choose whether to live or die; the absolute master of such a decision is the Creator alone, in whom we live and move and have our being. 10 Since we have been entrusted the gift of life as stewards, the Church clearly condemns euthanasia (physician assisted suicide or mercy killing ). 11 The POLST form could only be acceptable if it is used by individuals with well formed conscience. For a Catholic, individual choices are not absolute. Even though the person s individual conscience must be respected and understood as the most secret core and sanctuary of a man, 12 conscience is not the ultimate reason of our moral choices. 13 The foundation of our morality is the God-given truth, which could be known naturally through our reason. Our conscience, in fact, becomes free only by honoring and practicing such revealed truth. Human conscience could be erroneous; that is when man shows little concern for seeking what is true and good, and conscience gradually becomes almost blind from being accustomed to sin. 14 It is the most sacred mission of the Church to provide men and women with the opportunity to seek this objective truth. The individuality of someone s choice does not make that choice moral. What makes someone s choice moral is its harmony with truth. POLST is more than a form; it is a paradigm. The bright-colored POLST form comes with motivations, euphemisms, and specific ideas. Usually a facilitator is trained to conduct a POLST conversation. Even though the POLST form may include some good procedure when the need occurs, the POLST facilitator may mislead the individual in making morally sound choices. Individuals who are discerning using the POLST form or who have already signed it need to conduct a faith-filled LIFE conversation with a spiritual director, chaplain, or pastor. The POLST form contains very important information about someone s preferences in using life-sustaining treatment. Someone s LIFE conversation before signing a
Our Lives on a Bright-Colored Form 3 POLST form (or even before writing an advance directive document) should also include his or her physician or healthcare professional who knows and care for the individual s well being. The way the Wisconsin POLST form is designed requires the signature of a physician, any physician. An instrument that genuinely cares for someone s life and health needs to clearly include the view of someone s healthcare professional. Section F of the Wisconsin POLST form gives the option of the signature of the patient, parent of a minor, or a guardian. The reason why a document such as POLST gives that option is because this form contains the expression of human consent regarding lifesustaining treatment. When the patient is incompetent to provide his or her consent, then a parent or a guardian act on behalf of the critically ill person. Having said this, it is necessary to consider the following points: a) In Wisconsin, the signature of the patient, parent of a minor, or guardian is optional. Even further, the POLST form is filled out by the facilitator (a social worker, a chaplain, or a nurse) and become active medical orders immediately upon the signature of a physician. This qualifies the undermined importance POLST gives to the individual s consent. There is no legal way to determine whether or not the patient, parent of a minor, or guardian really knows what he or she is getting into, or if in fact he or she has given an informed consent. It seems a contradiction that the main goal of POLST is to ensure that the patient treatment preferences are honored throughout the healthcare system 15 and at the same time the requirement of his or her signature is optional and the completing of the form is done by someone else. b) About 25% to 77% of critically or terminally ill patients suffer from depression or anxiety. These highly prevalent disorders are frequently under-diagnosed in this setting, and the failure to properly treat them may subsequently prevent quality dying. The terminally ill is, in fact, part of the group who most likely commit suicide. 16 Depression and anxiety, like most mental disorders, prevent the individual to properly offer a morally sound consent. The spiritual asphyxiation most terminally ill individuals experience functions as an inner noise that prevents them to listen to the voice of the Good Shepherd, who calls them the join their pain to His. c) According to Wisconsin law, a guardian means a person appointed by a court under s. 54.10 to manage the income and assets and provide for the essential requirements for health and safety and the personal needs of a minor, an individual found incompetent, or a spendthrift. 17 A guardian, then, could or could not know the patient. Further more, a guardian (an in some exceptional cases, a parent) may not genuinely want or be concerned for the well being of the critically ill or dying person. POLST is generally for patients with health conditions that are life-limiting but not exclusively for such patients. Thus, POLST reaches beyond patients at the end of life to virtually any patient at any point in life. This potentially would allow refusal of treatment which could in fact benefit the patient and prevent untimely death or avoidable infirmity or disability. Further, the POLST form undermines the legislation a physician needs to follow to issue a do-not-resuscitate (DNR) bracelet in the state of Wisconsin. Under Wisconsin law, an attending physician may issue a DNR order for a qualified patient. A qualified patient means a person who is at least 18 years old and who either has a terminal condition or has a medical condition such that, were the person to
Our Lives on a Bright-Colored Form 4 suffer cardiac or pulmonary failure, resuscitation would be unsuccessful in restoring cardiac or respiratory function, the person would experience repeated cardiac or pulmonary failure within a short period before death occurs, or resuscitation would cause significant physical pain or harm that would outweigh the possibility the resuscitation would successfully restore cardiac or respiratory function for an indefinite period of time. 18 The POLST form removes these conditions in using DNR. It permits any patient to refuse any treatment (not just DNR) at any time for any reason in the event they lack decisional capacity; and healthcare professionals, directed by a doctor s medical order, would be required to carry out the order. 19 The POLST form legalizes someone s desire to die, undermining not only the State law, but also the Church teaching. The POLST form does not make distinctions among the different types of treatments. It goes beyond just DNR to include other treatments such as the provision of antibiotics, dialysis, and ventilation, which, in some circumstances, can be proportionately beneficial and provide comfort even when one approaches the end of life. POLST goes further to include the option to refuse food and water, which is ordinary care due to every human being unless gravely burdensome. 20 For certain types of patients (the terminally ill, for example) some of the life-sustaining treatments are disproportionate means, because they would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted To forego extraordinary or disproportionate means is not the equivalent of suicide or euthanasia; it rather expresses acceptance of the human condition in the face of death. 21 The refusal of ordinary or proportionate means is in principle immoral. The refusal of extraordinary or disproportionate means could be morally permitted. The POLST form makes no moral distinctions among the means. One may refuse an antibiotic in any given situation should the sick person becomes incompetent to make decisions. When need occurs, the POLST form should be followed first, before contacting a physician. Catholics believe that through human reasoning and conscience one may know God s law. POLST places the gift of life not on the sanctuary of human reasoning and conscience, but on a paper. Appropriate medical care takes the back seat. And the main concern is not the life and well being of the patient, but the accomplishment of what is written on the POLST form. The POLST form presents as optional what by its nature and our Christian faith is not. Treating the patient with dignity and respect; keeping him or her clean, warm, and dry; administering nutrition and hydration; caring for the patient s hygiene; and wound care are presented as optional on the POLST form. For a Catholic there is no other way of treating a sick person than with dignity and respect. The form does not indicate any outcome if the patient, parent of a minor or guardian decides not to check any of the boxes of section B. Doing so is contrary to fundamental principles of Catholic healthcare. Section D gives the patient, parent of a minor or guardian the option of refusing artificially administered nutrition and hydration. Such a refusal is in principle contrary to our Catholic faith. Nutrition and hydration are ordinary means. POLST forms can reduce delicate nuanced conversations with one's physician and loved ones about treatment possibilities to a matter of indicating either yes or no on a check-off list, creating forced choices. This, coupled with a perceived pressure to complete a POLST form so as to relieve others of the burden of decision making, can raise
Our Lives on a Bright-Colored Form 5 questions of voluntariness. This is a particular concern for vulnerable persons such as the poor, homeless, and disabled. Given these concerns, the AHBC opposes the use of the POLST form and paradigm as it is presented in the state of Wisconsin. The AHBC recognizes that this type of forms could be presented differently in others states. In Wisconsin, a deep review of motivations, procedures, wording, and principles needs to take place to properly use POLST as a tool that cares not only for the wellbeing and dignity of the patient, but also for God s gift of life. The AHBC invites Catholics and people of good will to carefully scrutinize the POLST paradigm, and strongly recommends discussing these matters with a spiritual director and a trusted healthcare professional. The Pastoral Letter from the Roman Catholic Bishops of Wisconsin, Now and at the Hour of Our Death, provides a good Catholic guide for those who are discerning and preparing for the end of earthly life. This document could be downloaded from, www.wisconsincatholic.org/revised06_endoflife_large_print.pdf. For those who have already signed a POLST form, the AHBC offers the following questions: How am I preparing myself and my loved ones for the end of earthly life? Am I considering a dialogue with a spiritual guidance or director? How do I want my healthcare providers to honor and respect this precious gift God has entrusted to me, life? How does this form reflect God s loving will in my life? Am I following the guidance of the POLST facilitator or the one of God, the Author of Life? Do I understand the nature and consequences of the life-sustaining treatments from the voice of the healthcare professional I have trusted and trust my physical and/or mental well being? Am I really expressing my faith-filled preferences regarding life-sustaining treatment for myself or my loved one through this form? Am I letting myself or my loved one be guided by God in making these important choices, or am I letting the tragedy of pain and suffering to lead my choices? Is my loved one really competent to make faith-filled choices regarding life-sustaining treatment? As a guardian or a parent, am I honoring God s image and God s gift of life in this person who has been entrusted to me? Am I being an authentic instrument of God s loving will in the life of this person who has been entrusted to me? Am I seeking death or am I accepting my human condition? Am I refusing ordinary or proportionate means? Why am I refusing an extraordinary or disproportionate means? Do I understand the moral and medical differences among all these treatments? When the need occurs, do I want a physician or healthcare professional to discern what is best for me? Or, do I want healthcare professionals ignore what their conscience tells them and follows the POLST form? Do I need to fill out this form? Am I placing myself and/or my loved one into the hands of God, the Author of Life? Physical death is part and the end of earthly life, 22 a consequence of sin, 23 and the door which opens wide on eternity and, for those who live in Christ, an experience of participation in the mystery of his Death and Resurrection. 24 Only in light of an accurate understanding of life, could men and women embrace the full meaning of death. Human life needs to be understood as a reality in-tension; that is, physical life is subordinated to eternal life. 25 The giving up of physical life, however, is not motivated by a superficial and misleading understanding of quality of life, 26 which arbitrarily assigns degrees of dignity to human life and presents suffering as an absolute opposite of happiness. 27 In explaining the redemptive meaning of suffering, our Wisconsin bishops stated, Joining our suffering to Christ becomes redemptive for ourselves and others. The room of a dying person can become a chapel where pain, suffering, and death are met with faith, hope, and love. However, a dying person may take whatever measures are needed to relieve pain. At the same time, in our suffering, the Paschal Mystery is lived out in each one of us as we accept our own mortality and,
Our Lives on a Bright-Colored Form 6 inspired by our faith, echo the words of Christ, "Father into your hands, I commend my spirit." (Luke 23:46) 28 It is through His death that Jesus reveals to us the fullness and the splendor of the gift of life, the ultimate returning journey to the Father, a dwelling place of eternal peace. Truly great must be the value of human life if the Son of God has taken it up and made it the instrument of the salvation of all humanity! 29 Father, I commit myself into your hands; Father, I trust in you; Father, I abandon myself to you; Father, do with me what you will; whatever you may do, I thank you; thank you for everything; I am ready for all, I accept all; I thank you for all. Let only your will be done in me, Lord, let only your will be done in all your creatures, in all your children, in all those whom your heart loves, I wish no more than this, O Lord. Into your hands I commend my soul; I offer it to you, Lord, with all the love of my heart, for I love you, and so need to give myself in love, to surrender myself into your hands, without reserve, and with boundless confidence, for you are my Father. (Benedict XVI, September 14, 2008). NOTES: 1 Special contribution of the members of the Archdiocesan Healthcare and Bioethics Committee, Hon. Michael B. Brennan, Dr. Krishna Das Gupta, Very Rev. Jan de Jong, Dr. Richard Fehring, Atty. Gordon Gianpietro, Dr. Carolyn Laabs, Dr. James Linn, Ms. Lydia Lococo, Dr. William Thorn, Dr. Michael White, and Very Rev. John Yockey. Other contributors were Dr. Mark Repenshek, Dr. Marisa Beffel, and Dr. Franklin Smith. 2 Also known as Physician Orders for Scope of Treatment (POST) and Medical Orders for Scope of Treatment (MOST). 3 Cf. History of the POLST Paradigm Initiative, in: www.ohsu.edu/polst/developing/history.htm 4 Cf. Susan E. Hickman et al., Use of the Physician Orders for Life-Sustaining Treatment (POLST) Paradigm in Hospice Setting, Journal of Palliative Medicine, 12/2, 2009, 133. 5 Susan E. Hickman et al., The POLST (Physician Orders for Life-Sustaining Treatment) Paradigm to Improve End-of- Life Care: Potential State Legal Barriers to Implementation, Religious and Cultures of East and West: Perspectives on Bioethics, Spring 2008, 119. 6 Respecting Choices, POLST Paradigm: Last Steps ACP, in: respectingchoices.org/training_certification/ national_courses/physician_orders_for_life-sustaining_treatment_%28polst%29_paradigm 7 USCCB, Ethical and Religious Directives for Catholic Healthcare Services, 24. 8 Catholic health care institutions offering care to persons in danger of death from illness, accident, advanced age, or similar condition should provide them with appropriate opportunities to prepare for death. Persons in danger of death should be provided with whatever information is necessary to help them understand their condition and have the opportunity to discuss their condition with their family members and care providers. They should also be offered the appropriate medical information that would make it possible to address the morally legitimate choices available to them (USCCB, Ethical and Religious Directives for Catholic Healthcare Services, 55). 9 Cf. Catechism of the Catholic Church, 1014; Sacred Congregation for the Doctrine of the Faith, Declaration on Euthanasia, May 5, 1980, Conclusion. 10 John Paul II, Evangelium vitae, 47. 11 By euthanasia is understood an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated (Congregation for the Doctrine of the Faith, Declaration on Euthanasia, May 5, 1980). 12 Gaudium et spes, 16. 13 The judgment of conscience does not establish the law; rather it bears witness to the authority of the natural law and of the practical reason with reference to the supreme good, whose attractiveness the human person perceives and whose commandments he accepts. Conscience is not an independent and exclusive capacity to decide what is good and what is evil. Rather there is profoundly imprinted upon it a principle of obedience vis-à-vis the objective norm which establishes and conditions the correspondence of its decisions with the commands and prohibitions which are at the basis of human behavior (John Paul II, Veritatis splendor, 60). 14 Gaudium et spes, 16.
Our Lives on a Bright-Colored Form 7 15 Cf. Susan E. Hickman et al., Use of the Physician Orders for Life-Sustaining Treatment (POLST) Paradigm in Hospice Setting, Journal of Palliative Medicine, 12/2, 2009, 133. 16 Cf. Robert L. Fine, Depression, Anxiety, and Delirium in the Terminally Ill Patient, in: www.ncbi.nlm.nih.gov/pmc/articles/pmc1291326/ 17 WI Statutes: Ch. 54, Guardianships and Conservatorships, 54.01(10). 18 Do-Not-Resuscitate (DNR) Information, Wisconsin Department of Health Services, in: www.dhs.wisconsin.gov/ ems/emssection/dnr.htm 19 E. Christian Brugger, Legalizing Euthanasia by Omission and Making it a Doctor s Order, in: www.zenit.org/article-33277?l=english. 20 Cf. USCCB, Ethical and Religious Directives for Catholic Healthcare Services, 58. 21 Congregation for the Doctrine of the Faith, Declaration on Euthanasia, May 5, 1980, IV. 22 Catechism of the Catholic Church, 1007. 23 Ibid., 1008. 24 John Paul II, Evangelium vitae, 97. 25 Cf. John Paul II, Address to the President of the Pontifical Academy of Life, February 19, 2005; Address to the President of the Pontifical Academy of Life, February 24, 1999; Congregation for the Doctrine of the Faith, Donum vitae, Introduction, 3-4. 26 Cf. John Paul II, Evangelium vitae, 23 27 Cf. John Paul II, Salvifici doloris, 9-14. 28 Roman Catholic Bishops of Wisconsin, Now and in the Hour of our Death, Pastoral Letter on the End of Life, 11. 29 John Paul II, Evangelium vitae, 33.