POLST: A Catholic moral dilemma (part one) Print
Heroes for Life
Thursday, Aug. 21, 2014 -- 12:00 AM

Author's note: "Love -- caritas -- is an extraordinary force which leads people to opt for courageous and generous engagement in the field of justice and peace. To defend the truth, to articulate it with humility and conviction, and to bear witness to it in life are therefore exacting and indispensable forms of charity. All people feel the interior impulse to love authentically: love and truth never abandon them completely, because these are the vocation planted by God in the heart and mind of every human person" (Pope Benedict XVI, Caritas in Veritate).

These words from Pope Emeritus Benedict XVI capture so well the weight of the pro-life mission. Working as a dining room server at a retirement home in high school, I formed friendships with the elderly community there. This experience was formative and heightened my awareness of the love that must infuse end-of-life care. In my research, I came across the controversial POLST form, an advance directive becoming commonly used in hospitals, hospices, and nursing homes.

The Physician's Orders for Life-Sustaining Treatments (POLST) form was created by the Center for Ethics in Health Care at Oregon Health & Science University. Its national implementation was funded in part by institutions that also financially support right-to-die organizations. Among these organizations is Compassion & Choices, formerly called The Hemlock Society, which from its inception sought to legalize euthanasia, or "mercy killing."

I spoke with Dr. Franklin Smith, contributing author for the Catholic Medical Association's White Paper on the Catholic moral position on the POLST paradigm, to learn about this complex and problematic topic. The Catholic moral dilemma with POLST is two-fold: that end-of-life decisions are made in advance, frequently without the counsel of a doctor, and that these decisions may be made on the basis of whether life is worth living rather than respecting the gift of life. Though our Catholic faith requires that we use all reasonable efforts to protect a life, we are not required to accept every treatment in every situation -- this should become clear in the discussion that follows.

-- Lillian Quinones is a 2013 graduate of St. Ambrose Academy in Madison. She is a sophomore at Hillsdale College in Hillsdale, Mich.

Dr. Franklin Smith
Dr. Franklin Smith
Meet Dr. Franklin Smith

Dr. Franklin Smith is a board certified urologist working in the Oconomowoc area. Born into a family of nine children in Chicago, he graduated from Northwestern University Medical School. He completed his residency in urology at the University of Chicago in 1987. After residency, he served as assistant professor of urology at the University of Wisconsin in Madison. Since 1993, he has worked in private practice. He is past president of the Milwaukee Guild of the Catholic Medical Association.

Dr. Smith has had an interest in end of life issues since the death of his father in 2004. For the past two years, he has served on a subcommittee of the Catholic Medical Association to examine a specific end-of-life directive, the POLST Working Group. One product of their work is the CMA White Paper on POLST, appearing in the May 2013 issue of the Linacre Quarterly.

Dr. Smith is happily married, the father of two children, and a member of St. Jerome Parish in Oconomowoc.

First in a two-part series on Physician’s Orders for Life-Sustaining Treatments (POLST). The series is based on author Lillian Quinones’ interviews with Dr. Franklin Smith.

POLST: Locks in restrictions on life-sustaining treatments

It is standard in medicine to use treatments that sustain the gift of life. For this purpose, POLST is unnecessary.

The innovation of POLST is to offer a new option, to limit or reject life-sustaining treatments and lock in these limitations as orders that must be followed now and in all future medical situations.

Thus the term is a misnomer: Physician Orders for Life-Sustaining Treatment. In reality, when POLST orders are written to withhold life-sustaining treatments, a patient needing treatment is expected to die as a result of these orders. Thus a careful examination of POLST is reasonable and necessary.

As medical orders, POLST is inflexible. Nurses and other caregivers must follow these orders, regardless of the patient's actual medical condition, and regardless of the patient's current decision-making abilities.

POLST orders "travel" with patients and remain in effect across all care settings: ambulance, nursing homes, hospital, etc. Fundamentally, it orients patients onto rigid "tracks" of treatment or non-treatment, which all caregivers must respect and follow -- no matter the appropriateness, the actual reasons, or how these choices were made.

Facilitators create doctor's orders

Examined in another way, Physician Orders for Life-Sustaining Treatments is a misnomer. The process of selecting POLST orders that limit life-sustaining treatments in many cases does not involve physicians.1

Rather, the creation of these doctor's orders is supervised by individuals ("facilitators") who are far less skilled. Facilitators are typically social workers, nurses, ward clerks, chaplains, and nursing home staff. They have conversations with patients to determine limits in life-sustaining treatments.

The facilitator completes the POLST form and forwards it to a doctor or nurse practitioner, who is expected to sign the form. Once signed, POLST orders must be followed.

No patient signature required

The patient's signature is not required on the form, nor is a personal doctor-patient discussion. Recent POLST research from Wisconsin showed that 95 percent of POLST forms were not signed by patients or by their surrogates.2

Thus whether the patient even knows of their form's existence or the orders written remains undocumented by the customary legal standard -- a patient's signature.

Facilitator role deviates from standard medical principles and practice

Physician informed consent, a principle of medical malpractice law, was established to ensure that patients receive complete, reliable information from their doctor so the patient can make good medical decisions and understand the consequences of those decisions.

Medical malpractice cases, in which a patient sues a doctor, are frequently decided by answering the question: did the doctor adequately inform the patient of all relevant information to make a decision in an unbiased manner? The information would include the patient's actual medical condition, treatment options, advantages, disadvantages, alternatives, expected results, possible complications, etc.

Facilitator informed consent departs from this legal standard, and it carries legal and ethical risks, even possible financial conflict of interest when health care system administrators assign non-physician employees to serve in this role.

Problems with facilitator training

A national center for training POLST facilitators, Respecting Choices, is located at Gundersen Clinic of La Crosse, Wis.3 Registration and facilitator certification requires no previous health care training or experience.

The training manual and materials appear negatively biased against various life-sustaining treatments. They appear to focus on the discomfort and invasiveness of treatments much more than the possibility of positive outcomes from short-term courses of treatment. For example, regarding the question of feeding tubes, the facilitator manual says to counsel patients as follows:

To assist you in making this decision, I'd like to give you some examples of the side effects that can occur because of receiving artificial nutrition and hydration. First, the artificial nutrition that is delivered through tubes often moves out the stomach and slips into the lungs, causing pneumonia. This is called aspiration. The artificial hydration that is delivered may also increase the amount of fluid the body has to absorb, causing extra fluid in the lungs, making it more difficult to breathe. The extra fluid also causes congestion in other parts of the body, causing pain and discomfort as well as the need to urinate more frequently.4

The facilitator's scripted explanation emphasizes problems and side effects that may occur, but leaves out how proper care of these tubes typically may prevent these problems.

Unfortunately, non-physician facilitators lack a doctor's experience to know proper feeding tube care and to witness life-saving benefits experienced by those unable to swallow. In this way, facilitator training can create negative attitudes toward life-sustaining treatments.

Many people who have lost the ability to swallow lead active and full lives while relying on feeding tubes. People who are seriously injured may need feeding tubes for a short period of time if they are to recover from their injuries.

Disability rights groups specifically cited Respecting Choices materials for negative bias, some of which were recently pulled from the market as a result.5 These disabled individuals view negative attitudes discouraging of life-sustaining treatments as a threat to their continued survival, saying, "If there is any bias, it should be toward encouraging patients to try these devices before ruling them out."6

Usurping the doctor's role

Doctors enter their profession by committing themselves to their patient's well-being, to defend them against outside encroachments during vulnerable periods of illness.

However, institutions that transfer the patient decision-making process from doctors to facilitators, who are trained with negatively-biased information, may be risking the lives of injured people, the elderly, people with disabilities, and other vulnerable individuals.

Doctor incentives to sign POLST

Where the POLST paradigm is implemented by a medical system, doctors are expected to sign POLST forms forwarded to them by facilitators. In some locations, doctor cooperation in signing POLST is tracked through the electronic medical record and they are financially rewarded or punished based on compliance.7

We expect the new models of care called for by The Affordable Care Act to increase these incentives. For example, Accountable Care Organizations will profit financially by any Medicare cost savings that may result by implementing the POLST paradigm.8

Financial incentive should not be a motive to sign orders that limit or deny treatment -- especially orders which the patients' doctor did not write. Fortunately, some doctors have refused to sign POLST forms because the ". . . choices selected . . . " (by facilitators) ". . . were not suitable for their clinical condition, were potentially injurious, and were not compatible with good medical care."9

1 Charles P. Sabatino and Naomi Karp, Improving Advanced Illness Care: The Evolution of State POLST Programs, 2011, available at http://assets.aarp.org/rgcenter/ppi/cons-prot/POLST- Report-04-11.pdf

2 Hickman, SE et al, Use of the Physician Orders for Life-Sustaining Treatment Program for Patients Being Discharged from the Hospital to the Nursing Facility, Journal of Palliative Medicine, 2014.

3 http://respectingchoices.org Sabatino and Carp, 2011, pg. 24.

4 Respecting Choices: Advance Care Planning Facilitator Course Manual, 2007, Chapter 4.12

5 Press Release: Disability Right Organizations Led By Not Dead Yet Issue Open Letter Criticizing Respecting Choices Program for Bias Against Feeding Tubes and Breathing Devices, December 20, 2013, available at: http://www.notdeadyet.org/2013/12/press-release-disability-rights-organizations-led-by-not-dead-yet-issue-open-letter-criticizing-respecting-choices-program-for-bias-against-feeding-tubes-and-breathing-devices.html

6 http://www.notdeadyet.org/2014/04/dialogue-begins-about-feeding-tubes-and-breathing-devices-with-respecting-choices-program.html

7 Nelson, S. E., and J. F. Tuohey. 2011. POLST: A Dangerous Development or a Useful Tool? Catholic Health Association Webinar June 28, 2011. (From Q&A after presentation).

8 http://www.nytimes.com/2012/11/25/opinion/sunday/end-of-life-health-care.html?_r=0

9 Signed correspondence from Pavela, SL et al, available on request.