Physician's Order for Life-Sustaining Treatment: Helpful or a New Threat?
Some ethicists see stronger danger at end of life with new form that patients can sign. 'A living will on steroids.'
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.