POLST: A Catholic moral dilemma (part two) Print
Heroes for Life
Thursday, Aug. 28, 2014 -- 12:00 AM

Author's note:  "God is the foundation of hope: not any god, but the God who has a human face and who has loved us to the end, each one of us and humanity in its entirety. His Kingdom is not an imaginary hereafter, situated in a future that will never arrive; his Kingdom is present wherever he is loved and wherever his love reaches us. His love alone gives us the possibility of soberly persevering day by day, without ceasing to be spurred on by hope, in a world which by its very nature is imperfect" (Pope Emeritus Benedict XVI, Spei Salvi).

The words of Pope Emeritus Benedict XVI articulate the unique aspect of hope in the Catholic paradigm. In Part II of POLST: A Catholic Moral Dilemma, Dr. Franklin Smith contrasts POLST to the Catholic approach to end-of-life decision-making. -- 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.

Second 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.

When to make decisions regarding end of life care

POLST advocates propose making advance medical decisions to limit future life-sustaining treatments, in other words, before the medical need arises.

For example, facilitator handouts advise individuals that "The time to make this choice . . ." (on feeding tubes, CPR, etc) “. . . is when you feel well."10 Unfortunately, treatment selections made in advance suffer from a fatal flaw. One cannot accurately predict future situations and conditions and whether the advance decision will be the correct one or the preferred one at the time of the actual future situation.

When confronted with a condition that warrants treatment, most people decide they want treatment -- and that is their right. A well-documented example is the "disability paradox" -- people who previously thought they would not want to live should they become disabled in the future. Later when the disability did occur, they changed their minds and adjusted, often finding that they were now happier than before their disability!11

Our Catholic faith says that when God allows a cross to come into our lives, He also provides the grace to be able to receive that cross. Unfortunately, POLST advance decisions that reject life-sustaining care can prematurely end lives and eliminate all possible future choices that the patient may have wished to consider.

In-the-moment decision-making

A model of when to decide that completely avoids such problems is known as "in-the-moment decision-making."12

With few exceptions, there is no specific medical requirement to make decisions in advance. When a new medical situation occurs and our health takes a sudden turn for the worse, we can discuss with our doctor what treatment options may be considered, to make intelligent decisions, with the best possible information, in the moment of medical need.

Are there newer options to consider that weren't available in the past? What are the benefits, risks, and burdens of each option? What if I do nothing? Examining these questions in the moment of medical need with the managing doctor constitutes true informed consent.

Wisconsin bishops' recommendation

There may come a time when you are incapacitated and unable to communicate or make decisions. The Wisconsin bishops recommend that you plan for this situation and appoint a person whom you trust to make medical decisions on your behalf.13 This person is known as your Health Care Power of Attorney.

You should discuss with him or her your attitudes about health care. You may wish to help prepare the person by having him or her accompany you to your next yearly doctor's visit, to become acquainted with your doctor and to discuss your overall medical condition.

Catholic reasoning for life-sustaining treatments

POLST conversations with patients often begin with a discussion of the topic of "living well,"14 asking specifically what makes life "worth living" to the patient -- which might be golf, good books, self-sufficiency, etc. Such "quality of life" discussions may lead the facilitator or patient to conclude that future life-sustaining treatments should be rejected in the event that his health takes a serious turn for the worse and those good things might not be enjoyed.

Herein lies the threat of euthanasia -- the rejection of life because it is deemed "not worth living." As Catholics we may reasonably reject treatments because we determine they are overly burdensome; but we must never deliberately reject the gift of life per se, even if life appears burdensome to the patient, to caregivers, or to the family.

Ordinary and extraordinary measures

Catholics are not required to undergo any and all treatments, but we should always seek to preserve life using ordinary, proportionate measures.

Obvious examples of ordinary care that must be provided are food, drink, warmth, and cleanliness. We may accept, but are not required to accept, disproportionate or "extraordinary" care -- where the patient finds the treatment to be unduly burdensome compared to the expected benefit, treatment that will cause disproportionate suffering with little hope of success.

In such cases, a moral decision may be made to refuse the treatment. Notice the distinction: it is the disproportionate burdens of treatment that are rejected; it is not the burdens of a "poor quality of life" that are rejected.

A recent example in the news illustrates the difference, (although this did not involve a POLST directive). A man with dementia, living at home, stepped outside, saw a rattlesnake, and was bit. His family found him very ill and he was rushed by ambulance to the hospital. Doctors said they needed family permission to administer the anti-venom to save his life.

Because the family anticipated further worsening of his dementia over time, they rejected the anti-venom so that he would die from the snakebite -- as they described it, "with dignity."15 Here, the treatment was not burdensome: an injection that might completely reverse the problem. Without it, he would die. His family rejected the treatment because he had dementia and anticipated a poor "quality of life." Choosing to reject a life because it is burdensome constitutes euthanasia by omission because of the intent to bring on death.

The ultimate moral analysis must carefully consider the specific medical condition, treatment options, and surrounding circumstances, but, of course, all of these facts are only apparent at the actual time of illness and cannot be known in advance. Thus advance decisions such as POLST orders are not only medically dangerous; they are also morally risky choices.

The doctor/patient relationship under attack

A cornerstone of the medical profession is the doctor/patient relationship -- a special relationship of trust and protection for the patient. Who else but the doctor can best advise the patient in complicated medical decisions and will work for them in the face of aggressive insurance plans and stand with them in threatening health situations?

For doctors, in this era of increasing government regulations, decreasing reimbursement, and struggles with the electronic medical record, it is the love for the patient that keeps them coming back to work and represents the primary reason they entered the profession.

The doctor/patient relationship is under attack but must be defended, by patients and doctors, if we are to prevent governmental and institutional encroachments such as the POLST Paradigm. When financial pressures are used to justify intrusions into the sacred relationship between doctor and patient, in the end it is patients who will suffer.

What can I do, Dr. Smith?

1. Because Wisconsin POLST forms usually bear no patient signature, there may be situations where a facilitator completed a POLST after a patient visit and the patient is not even aware of it. If you or your loved one is in a nursing home or hospital, ask, "Do you use POLST forms here?" If the answer is yes, say, "I don't want a POLST form. I want to talk to the doctor" and ask the doctor to write an order: "No POLST conversations and no POLST form."

2. Be very careful when health care staff ask about your understanding of "living well" and "quality of life" -- often a lead-in to discussing life-sustaining treatments. In those situations you can say, "I'm uncomfortable talking about this with you, because my life itself is so precious. Is this about POLST?"

3. Become informed: Read the Wisconsin bishops' statement, Upholding the Dignity of Human Life -- A Pastoral Statement on Physician Orders for Life-Sustaining Treatment (POLST) from the Catholic bishops of Wisconsin. Ask your parish priest to place it as an insert in your church bulletin. Become familiar with the teachings of the Church on medical decision-making.

4. Tell others. Make POLST a common household term by sharing your concerns with friends and family.

5. Pray for the medical profession and pray for courage for your doctor to protect the sacred doctor/patient relationship.

10 Respecting Choices Fact Sheets, 2011: Tube Feeding: What You Should Know; CPR: What You Should Know; and Help With Breathing: What You Should Know.

11 Peter A. Ubel, et al., Mismanaging the Unimaginable: The Disability Paradox and Health Care Decision Making, 24 Health Psychology S57 (July, 2005).

12 Sudore, R. L., and T. R. Fried. 2010. Redefining the ‘Planning’ in advance care planning: preparing for end-of-life decision making. Annals of Internal Medicine s153:256–61.

13 Now and At the Hour of Our Death, A Pastoral Letter From the Roman Catholic Bishops of Wisconsin On End of Life Decisions, available at: http://www.wisconsincatholic.org/NATHOOD%202013%20Booklet%20Form.pdf

14 Respecting Choices: Advance Care Planning Facilitator Course Manual, 2007, Chapter 4.2 and 5.2-5.4.

15 https://scripps.endplay.com/web/wptv/dpp/news/region_martin_county/hobe_sound/richard-flora-snake-bite-victim-family-doesnt-give--antivenin-because-he-had-alzheimers-dnr