WASHINGTON — A patient in a nursing home or hospital is increasingly likely to be asked to sign a form with a benign-sounding name: Physician’s Order for Life-Sustaining Treatment.
A brightly colored document that is one page, printed on both sides, with boxes to be checked off regarding medical treatment — or the withholding of treatment — the Physician’s Order for Life-Sustaining Treatment (Polst), in an instrument for dealing with end-of-life decisions if the patient is incapacitated.
Once signed, the Polst accompanies the patient to any new medical facility. Some critics say that it is difficult for a patient to make changes in the document.
The Polst was developed in the early 1990s at the Center for Ethics in Health Care at the Oregon Health and Science University, a foundation that, according to its website, “envisions health care that is compassionate, just and respectful.”
Many states are developing legislation to make the Polst available. It is already considered standard in Oregon, New York, Pennsylvania, Washington, West Virginia and Wisconsin.
“What Polst does is roll together several end-of-life instruments to bring clarity and certainty to treatment decisions. It tilts in favor of not doing things because the [normal] presumption is in favor of treatment,” said John Brehany, executive director of the Catholic Medical Association. “If you go into cardiac arrest, they have to treat you unless you have a Do Not Resuscitate order.”
Not, however, if you have a Polst or living will on file.
A living will “absolves a physician of the liability” of not providing life-sustaining treatment to a patient who meets certain criteria,” said Brehany. “There is still room for some discretion about whether it is appropriate to withdraw or withhold these interventions.” The Polst carries even more weight: Unlike the living will, the Polst is an actionable medical order, signed by a physician. Its directives must be obeyed immediately and without regard to the judgment of the medical team on the scene.
“The Polst is a living will on steroids,” said E. Christian Brugger, who holds the Cardinal Stafford Chair of Moral Theology at St. John Vianney Theological Seminary in Denver and is one of a number of Catholic ethicists concerned about the emergence of the Polst. “The real danger is that people who sign a Polst often don’t understand how powerful this instrument can be.”
Brugger wrote in Ethics & Medics, a journal published by the National Catholic Bioethics Center, that the national push for the implementation of the Polst paradigm “seems also to be fiscally driven.”
Who Is Pushing Polst
Father John Tuohey, on the other hand, director of Providence Center for Health Care Ethics, Providence St. Vincent Medical Center in Portland, Ore., and Marian Hodges, a member of the Connections palliative-care team at Providence Portland Medical Center and its director of palliative care, however, wrote an article in support of Polst in Health Progress, a publication of the Catholic Health Association of the United States.
Father Tuohey and Hodges argued that a Polst reflects the patient’s will and provides for “clinically appropriate care” at the end of life. They argued that a Polst could prevent burdensome and unnecessary treatment.
“You have arguments by defenders that make these documents seem innocent,” Brugger said. “But the pressure is always in favor of removal of treatment.”
A resident at a nursing facility is given a Polst form with boxes to check, supposedly to reflect what the patient would want done if incapacitated.
A typical Polst form — this one used in Oregon — shows why ethicists such as Brehany and Brugger are concerned. The patient is asked what should be done if he has a pulse and is breathing but is incapacitated. The three options are comfort measures only, limited additional interventions (IV fluid, etc.) and full treatment. There are also three choices regarding administering antibiotics to such a patient: no antibiotics, limited use of antibiotics and “use antibiotics if medically indicated.”
With regard to artificially administered nutrition delivered by a tube, the three choices are not having a tube at all, “defined trial period of artificial nutrition tube” and “long-term nutrition tube.”
“The ethical guidelines for Catholic hospitals — called the ‘Ethical and Religious Directives’ — state clearly that the administration of food and water to all patients who need them to survive is a moral obligation,” said Brugger. “The POLST form by design permits any patient for any reason at any time to direct that food and water should be withheld. No wonder it’s the document of choice by Compassion & Choices (formerly the Hemlock Society).”
Pope John Paul II, in a 2004 address at the international congress on “Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas,” stated: “There are some who cast doubt on the persistence of the ‘human quality’ itself, almost as if the adjective ‘vegetative’ (whose use is now solidly established), which symbolically describes a clinical state, could or should be instead applied to the sick as such, actually demeaning their value and personal dignity. In this sense, it must be noted that this term, even when confined to the clinical context, is certainly not the most felicitous when applied to human beings. In opposition to such trends of thought, I feel the duty to reaffirm strongly that the intrinsic value and personal dignity of every human being do not change, no matter what the concrete circumstances of his or her life. A man, even if seriously ill or disabled in the exercise of his highest functions, is and always will be a man, and he will never become a ‘vegetable’ or an ‘animal.’”
He added, “The sick person in a vegetative state, awaiting recovery or a natural end, still has the right to basic health care (nutrition, hydration, cleanliness, warmth, etc.) and to the prevention of complications related to his confinement to bed. He also has the right to appropriate rehabilitative care and to be monitored for clinical signs of eventual recovery.”
The Pope continued: “The administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act. Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering.”
Brugger and Brehany observed that the options for withholding treatment are listed first on a Polst form.
“While there are many good people behind Polst,” said Rita Marker, a lawyer and executive director of International Taskforce on Euthanasia and Assisted Suicide, “this could evolve into a really dangerous document. Look at who is pushing Polst.”
Compassion & Choices, formed by the merger of the Hemlock Society and another euthanasia group, states on its website: “The Polst is considered the strongest, most explicit form of patient directive for care.”
Hard to Revoke
Not everybody agrees. California Advocates for Nursing Home Reform (CANHR), a nonprofit advocacy group, did a survey that interviewed long-term-care ombudsmen in California. The study found that many elderly patients in nursing facilities erroneously are told that signing a Polst is required.
There is no limit on who can sign for a patient, the Polst is harder to revoke than other advanced-care directives, and the physicians who sign the instruments have often never even met the patient.
Perhaps most alarmingly, however, the survey found that “accompanying handouts may manipulate patients’ choices.” For example, the material describes how CPR can cause broken ribs and brain damage. “The handouts are clearly intended to convince patients or their representatives to forgo CPR,” the study found.
“Facilitators,” who may be social workers or clergy with no medical training, are often the only ones who present the Polst to patients. Marker said that these facilitators are “basically taught to follow a script.” She said that facilitators might say things such as, “We find that most people would not want to continue to live in a vegetative state.” They “focus on what you wouldn’t want” done.
“The problem is that you’re trying to make decisions today that may not come into effect for five or ten years,” said Brehany. “You don’t know what your condition will be and what medical advances will have been made by then.
“You’re 60 and healthy, and you’re asked ‘Do you want to be hooked up to a lot of machines?’ But when the same person is 70 and might be going through a temporary rough patch, nothing will be done because of the Polst signed a decade earlier,” he said.
“The Catholic Church has never endorsed the idea that a person has to stay alive at all costs,” said Brugger. “If a type of treatment promises no reasonable hope of benefit — that is, it’s futile — or if in the judgment of the patient it would be excessively burdensome to undergo, then refusing its administration would not pose an ethical problem,” said Brugger. “But the Polst document codifies a much more extreme conception of autonomy, empowering patients to refuse life-sustaining care for reasons stretching much wider than futility or excessive burden.”
The Catechism teaches that discontinuing medical procedures that are burdensome, dangerous, extraordinary or disproportionate to the expected outcome can be legitimate; it is the refusal of ‘overzealous’ treatment. Here one does not will to cause death; one’s inability to impede it is merely accepted” (2278).
So what can a Catholic do to make sure that, if he becomes unconscious, treatment will reflect what is best and be in harmony with Catholic values? Brehany and Brugger urge people to appoint a proxy who knows their wishes, respects Catholic teaching and has power of attorney.
What can elderly people who have no family do?
“If you don’t have somebody in the family, ask your parish priest,” said Brugger, who tells priests in the Denver Archdiocese that, despite the heavy burdens of their calling, they should make themselves available to perform this service.
Charlotte Hays writes from Washington.
Tim Drake: Register Radio: Rome's March for Life & Physician's Orders
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The POLST form IS a problem and hasn’t done anything to relieve confusion or uncertainty about what to do for elderly patients/residents, especially in nursing homes. You fail to mention that often, the person who is expected to “facilitate” the completion of this form is the nurse in the nursing home. As a nursing director, I instruct my staff that the explicit instructions with the form - at least in California-are that it is to be the physician/patient/family who complete this form and our only responsibility is to let patients know it’s available.
Food and fluids offered via feeding tube is NOT a benign procedure and it should be remembered that most people may be OFFERED these things up to the end of life without the use of a feeding tube. Feeding tubes are painful and usually lead to complications such as infection at the site, gastrointestinal distress and pneumonia. I wish more people would ask the nurses about these things…
Carla—I think most people automatically think of a Terri Schiavo situation when they think of removing (or not using) a feeding tube—a healthy but seriously handicapped person who only needs basic care. A feeding tube at the end of life can be a serious burden.
I worked in ICU stepdown for 8 years, and I feel like there has been too little talk between patients and doctors about end of life care. Too often, terminal patients are given futile care. The patient population I worked with were folks with end-stage heart failure, and usually had kidney failure and diabetes to go with it. Physicians fail to address with these patients the natural course of their illness. Watching a 90 year old with end-stage heart failure get painful and futile interventions, to me, seemed to strip her of her dignity.
I think there is a fine line to walk between respecting the dignity of the human person and falling into the mindset of avoiding suffering/saving money/etc. I think it is best to be frank with patients and families, and give them the facts. It is true that CPR is rarely successful, and it is not a biased statement (per the article).
I think the quote from the Catechism sums it up best: “The Catechism teaches that discontinuing medical procedures that are burdensome, dangerous, extraordinary or disproportionate to the expected outcome can be legitimate; it is the refusal of ‘overzealous’ treatment. Here one does not will to cause death; one’s inability to impede it is merely accepted” (2278).”
I think we are just still in the stages of trying to define as a society what is “overzealous” treatment. Only that can be determined per each patient’s individual situation.
It’s as though each of us needs a very astute moral theologian visiting us in the hospital when we reach that age. The Church should construct a form for all Catholics that is totally without flaw and available worldwide. We hand it to the hospital to supervene their forms.
Old people should really examine the documents they sign before they sign it. Or else they might find themselves in the hospital for something not too minor but not major with breathing tubes and find out they are not allowed to have an IV because they signed something. So die of a slow starvation.
When my life isn’t worth living (when I can’t enjoy my Lions losing), I deserve, thru free will, to check out when I want. This form I would sign in a heartbeat (pun intended)
In regards to the comments above that suggest “a feeding tube at the end of life can be a serious burden” and “feedings tubes are painful and lead to complications” I offer an alternative view. As a geriatrician in long term care and medical director I find our culture is so strongly opposed to avoiding suffering at all costs that patients are often “starved to death” by well-meaning families and practitioners who believe food and water are “extraordinary treatment.” A feeding tube is not the answer in every situation but I have had patients maintained on feeding tubes for over ten years without one pneumonia, bedsore or peg site infection.
I was one of the co-authors in a recent article published by Dr. John Howland in the Linacre Quarterly that outlines the appropriate use of feeding tubes in line with Catholic medical ethics. A bishop in line with the Church’s teachings guided us throughout the writing of the article and is co-author as well. I encourage the readers to go to this link to read and download the article.
https://www.dropbox.com/s/sgav8t00sq3zm85/When to Recommend a PEG Tube.pdf
Thank you for addressing the implicit danger with the POLST forms. As a physician who has seen many patients arrive at the hospital with POLST forms, I have long been convinced that these (and “Living Wills”) are great and appropriate - but only in a VERY LIMITED set of scenarios: for patients with diseases with poor prognoses in the SHORT-TERM.
It’s a deadly disservice to patients to be encouraged to complete a “Living Will” or a POLST based on the stoking of generalized, worse-case scenario fears. Life and death decisions need to be based on individualized risks and potentials for good outcomes in real-time, or close enough to real-time to be meaningful.
I can’t tell you how many times I’ve encountered “ridiculously healthy” patients, in the hospital for some easily treated acute illness who have a “Living Will” (calling for no X - but a brief course of X will cure Joe’s acute illness and get him home fast). If he were temporarily comatose or just confused - often occurs transiently during an acute illness (eg in pneumonia, out of control diabetes, etc), he probably wouldn’t get X and would die!
And worst of all, many such patients just happened to, half-thinkingly over a few minutes, fill out this form after their lawyer suggested they do so when they went in just to have a Will (as in last will and testament) drafted! Be careful folks and avoid these forms that call for you - typically non-medical persons even - to try to predict what treatments you might want perhaps 10-20 years from now should you temporarily or permanently become unable to say. How the heck would you know?!
POLST can be argued as an improvement in the living will. There are problems with the POLST and living wills. These documents have an intended purpose to provide autonomy and decrease healthcare spending and utilization. There issue become state to state variation in forms, structure and terminology. Additionally these documents lack safe guards. They are documents with good intentions but have unintended consequences which become patient safety issues. These documents have never been tested with respect to patient safety. I would encourage those with interest in these forms and documents to review the TRIAD studies I, II, & III.
As I am 89 years old, I know the quality of life does not get better. I have begged my family and my doctors know that I want no extra measures taken to prolong my life.
I am sorry to say that many of our priests here in the Cleveland Diocese do not have a bishop who advocates for anything but raising money.
When I end up in the hospital the first thing I ask for is the anointing of the sick. It has been my solace.
@ Drs. Mirachi, Rentler and “O”: I find your comments very interesting. I am wondering: “what do you all think of Hospice Care?” I hope I get answers on this, even from the nurses. Thank you in advance.
Years ago I signed a “Living Will” but now I live in another State and will make our a new Will, so I have to decide on the “Living Will” again.
The link in Dr. Rentler’s post does not work. It only gives an error message.
I am a Canadian and we face a similar document in Canada—a DO NOT document. Last year I took my mother to the Emergency Unit of a Catholic Hospital for pain. After 3 visits on 3 different days she given a ‘diagnosis’ of constipation and they started treatment. She was 90 years old but with sound mind. Still a young attending nurse asked me to sign this DNR document for her; I asked her to talk to my mother herself. She went on to explain the broken ribs complications, unnecessary pain and told me how she helped her grandmother sign it. I pointed out that she as not anywhere near death, but under the pressure signed it. I recalled how our family had to make such decisions for my grandmother and my mother-in-law WHEN IT WAS TIME. Our decisions were based upon the teachings of the Church and the state of the person we loved at that time. Before the hour was over I revoked my signature. The shift changed and an older doctor came on duty, ordered some X-rays and discovered Mom had 3 fractured vertebrae. She was admitted and treated. During that time someone did approach her with the DNR document, which she refused to sign. It seemed to me that the DNR “attitude” affected the medical treatment of my mother who was not properly diagnosed and treated initially,
I see this as one more slip down that ugly slope.
Living wills and DNR orders are now a nationwide patient safety risk according to the TRIAD I, II & III studies. I would suggest being very careful and not advising anyone you have a living will until a patient is truly in fact terminal. These documents and orders do affect care and treatment.
Dear Old Sue,
I think that, in general, Hospice Care is great. That comes with the obvious caveat that flawed humans can find ways of doing anything poorly, but in the hospitals where Ive worked, Ive witnessed only competant, caring, comprehensive, respectful care. Ive read things in some ultra-conservative Catholic media that paints all Hospice as if the nurses and doctors are all a bunch of godless mercykillers…that is simply NOT what I have observed in 26 years of nursing.
The Physicians here have made some good points especially saying that POLST is not designed for peopel who arent VERY sick and looking shortly at end-of-life issues. It is my understanding that POLST was designed because too many terminaly ill people seeking to live out thier last days and die in peace were subjected to sudden, extreme, painful & futile care if anyone in their midst panicked and called 911….and every family has that one lunatic that thinks that its horrible to “let auntie die” even if she is genuinely at the end of her natural life.
I agree that the UCCSB should draft a Catholic Advance Directive that everyone could use. We have one on the website of our diocese and its not perfect, but its good.
I think the MOST important thing is for the extreme right wing lunatic fringe to stop acting like Advance Directives are all tools of the devil that doctors will use to kill you. Like I mentioned above, I have read things in the conservative media that warn old people that an Advance Directive will be used as an excuse to not care for them…that is SO WRONG on SO MANY levels. Look at the word “DIRECTIVE” it is what it says, a tool to direct what we want our care to be. If you want full-court-press resuscitation with a ventilator, kidney dialysis, feeding tube and every other intervention ever invented my humanity, they you can SAY SO.
If your Advance Directive is clear and detailed enough, you wont need a POLST. I have mine written and witnessed by the MD leader of the Ethics Committee.
To Sue: in answer to your queries,
1) Hospice - when true to its original conception - is a wonderful resource! However, some hospices are no longer operated fully in the spirit of the original hospice concept. Some hospices have, in effect, been “taken over” by administrators and/or staff who have a perverted view of what people need at the twilight of their lives. Proponents of assisted suicide and euthanasia have increasingly been moving in to the hospice world. That said, it’s extremely important to recognize that many hospices remain true to mission and folks would do themselves/their loved ones a disservice to presume bad things about all hospices causing them to miss out on the benefits of hospice. I’d suggest asking around about your local hospice/s (before the need arises if possible), perhaps visit the location/s, check out their website and testimonials if any, become a hospice volunteer if able, and just observe in a low-key manner while helping out.
2) One (of many) problem with “Living Wills” is that frankly, busy doctors often don’t read and recognize the significance of the part that (typically) mentions that this only applies in certain irreversible conditions (eg “less than 6 months to live”, “permanent vegetative state”) and they just say, in passing, to the patient as she’s being admitted, “OK, so according to your “Living Will” here, you don’t want to be resuscitated if your heart stops or you stop breathing, right?”, (without the caveat that this would only apply if the condition was believed to be irreversible/“terminal”). This kind of sloppiness is less likely to happen, I think, in scenarios in which the doctor thinks the document might actually become relevant during this admission - but sometimes patients get admitted for one low risk thing and then unexpectedly become critically ill…and then there’s that “Do Not Resuscitate/Do Not Intubate” order on the chart (or POLST) and the chances are quite low that that doctor, or perhaps moreso different doctors/nurses who might happen to be on the scene after the original doctor has gone home and the patient abruptly becomes critically ill, will go against these orders.
So the indiscriminate push for everybody to have a “Living Will” or POLST or similar binding document is fraught with danger and is downright reckless in my judgement. Some patients absolutely should have such a document (however it might direct healthcare personnel) - but this should be based on the relevant and current facts of each individual.
Hope that helps. Have your eyes wide open, do some low-key investigating, and decide from there about your local hospice. If problems there, perhaps it can be turned around by locals working together to help restore its true mission. Often staff may have simply been swept into the wrong mindset and can be swept back into the right mindset with the right kind of constructive attention.
For most patients, all that is needed is a trustworthy substitute decision-maker who you designate to make healthcare-related decisions for you should you be temporarily or permanently unable to do so. You could check with the local hospital if they happen to have a blank “Durable Power of Attorney for Healthcare Decision-Making” form that you could review. Imagine they’d give you one even if you’re not a current patient. You could fill it out per instructions on the form (no lawyer often needed, nor doctor, but needs to be witnessed and notarized). In most (all?) states, decision-making authority automatically goes to certain relatives in a priority order, ie if one doesn’t have a DPOA-HC, “Living Will”, etc., in case one is unable to make own decisions. Spouse is typically (probably always) the 1st line decision-maker though older folks are more likely to be single (eg widowed). Whoever decides is supposed to decide how YOU would decide so it’s wise and kind to that person if you can apprise them of your wishes including how you’d think things through depending on facts before you.
Here is the link, I hope it works this time. https://www.dropbox.com/s/sgav8t00sq3zm85/When to Recommend a PEG Tube.pdf
I do believe that hospice is useful in palliating symptoms for the patient with a short time to live. Hopeice care should never be equated with trying to “hurry along the “end” so the patient doesn’t have to suffer.” Attempting to shorten a person’s life by increasing doses of medication, if not needed for severe pain or symptom relief is euthanasia.
When filling out a per-certification form for the hospital where I was giving birth, one question asked if I had a living-will and if so, to bring a copy to the hospital the day of giving birth. Also there, they asked me if I had a living will and wanted to know if I would sign a DNR as well. I’m in my 20’s, I’ll take the chance that I’ll have broken ribs and pain. I thought it was ridiculous!
Kate, if the hospital was truly asking you to sign a Do Not Resuscitate request - and not instead asking you to specify your wishes regarding resuscitation (Full Code/Resuscitate…..OR Do Not Resuscitate) - then you should make a written complaint to the hospital. They need to be alerted to the awful impression this solicitation created. It’s possible the particular staff member was poorly trained and asked something that the administration and physician leadership sincerely didn’t intend. If, on the other hand, this was par for the course there, it’s likewise necessary that patient dissatisfaction with this particular incident and underlying philosophy be registered. It seems likely that at least some power-that-be there will have the same natural reaction as you, that this is ridiculous (and awful and unacceptable too) and may simply be unaware without you’re bringing it to their attention.
So even if your child was born months or a few years ago, you could write in opening with, “Despite a largely wonderful experience giving birth to my child at your wonderful hospital in—/2010, it has always bothered me that . . . “. They may not be able to look into the specifics of your experience if a lot of time has passed but your letter, especially if respectful and constructive, could serve to put this concern on the radar at the hospital and perhaps spare other delivering moms and other patients insensitive questioning like that. It’s probable that all hospitals have to offer patients the opportunity of specifying a “code status” (wishes regarding whether to be resuscitated or not) - but nobody has to ask if you’d like to request non-resuscitation!
The acronym “Polst” strangley reminds us of a “Poltergeist,” an evil spirit who loves to cause trouble.
Having been in the health care ministry now for over 25 years, the advice of “Brehany and Brugger urging people to appoint a proxy who knows their wishes, respects Catholic teaching, and has their power of attorney” is absolutely correct. But, beware: the person who has a patient’s “advanced directive” may find themselves at odds with the patient’s family members and, as such, will receive much spiritual warfare. Our advice is to hold on tight to doing the will of God.
As an ER nurse and someone who just lost her mother to breast cancer, I feel I have some insight into this difficult issue.
Feeding tubes are one of those hard things for me as a nurse. Once in, they are hard to get taken out. I have seen extremely obese (over 350 pounds) mostly vegetative patients with no voluntary movement and end-stage kidney failure where the liquid food is literally pouring out of their body. And their family still comes in and asks them to “Hang in there”!!
There is a problem in our society where we don’t seem to get the fact that WE ARE ALL GOING TO DIE AND THIS IS OKAY. I’m not saying we should actively try to kill someone, but when a 90 year old person’s heart stops beating they should be allowed to go on. I HATE doing CPR on someone that age. I feel like I am violating them, and taking their dignity away. The sad fact is that unless (at that age or if you have some sort of terminal illness) you have a DNR we HAVE TO DO ALL LIFE SAVING MEASURES. Even if they will more than likely end in your spending the remainder of your days on multiple tubes to keep your body alive. There is nothing dignified about a lot of what we do. Most people can write their Advanced Directives in such a way so that you get necessary care (ie fluids, food and water always offered, perhaps an NG tube for short term feeding, antibiotics for infection) and of course people should always be treated with dignity - personal care and changing. But sometimes dignity IS letting a person go on to be with the Lord.
When my mom was in her last few weeks, we continued to offer her food and fluids. She continued to take ice chips up until 2 days before death, but would refuse food. Because she had a brain tumor, we knew that putting in a feeding tube would be unnecessarily painful and that she could not eat anything without getting nauseous. If a person does not want to eat…they should be allowed that choice, shouldn’t they?
Such a tough issue…all the way around, but all decisions should be made with the understanding that we will all die sometime. We have to stop being afraid of that.
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