Among the most difficult medical decisions are those that must be made when patients can no longer speak for themselves. For that reason, more people are turning to various forms of “advance directives” to outline their wishes regarding medical treatment ahead of time.
Minnesota’s bishops, however, recently issued a new pastoral statement raising ethical concerns about an end-of-life medical care form known as “Provider Orders for Life-Sustaining Treatment,” or POLST.
“We believe that there are sufficient and significant ethical concerns that argue against its use for advance-care planning,” the bishops said in a statement titled “Stewards of the Gift of Life.”
Like advance directives, POLST forms aim to help ensure a patient’s wishes for medical care are carried out in the final stages of life. But, while advance directives allow patients to state treatment preferences, POLST forms constitute standing medical orders signed by a physician or another health care practitioner who can issue such orders.
POLST forms are increasingly being used around the country and were endorsed by the Minnesota Medical Association in 2009. Many hospitals and long-term care facilities — including Catholic health care providers — are using them.
A joint study committee composed of members of the Minnesota Catholic Conference, the public policy voice of the state’s bishops, and the Catholic Health Association of Minnesota studied the issue in depth for more than a year to give the bishops guidance on the issue, said Jason Adkins, MCC executive director. Committee members included doctors, nurses, ethicists, lawyers and health care providers.
The archdiocesan Commission on Biomedical Ethics was also consulted on the issue, he said.
One concern the bishops have about POLST forms is that they fail to acknowledge that patients can’t truly give informed consent for treatments when the variables surrounding a future medical condition are unknown.
“From a Catholic perspective, making a morally sound decision regarding end-of-life care calls for informed consent based on information related to the actual circumstances and medical conditions at a particular moment,” the bishops said.
“For both patients and providers, it is difficult to determine in advance whether specific medical treatments will be absolutely necessary or optional,” they note. “Though we have some ability to determine a person’s course of illness, we do not have absolute certainty. Therefore, any tool created to guide medical management must take these predictive limitations into consideration.”
POLST forms risk oversimplifying the medical-decision making process, the bishops said.
“Decisions depending upon factors such as the benefits, expected outcomes, and the risks or burdens of the treatment are oversimplified by ‘one-size-fits-all’ checkboxes, without the benefit of clinical context,” they said. “As a result, using POLST bears the risk that an indication may be made to withhold treatment that, under certain unforeseen circumstances, the patient would want to receive.”
Teresa Tawil, a gerontological nurse practitioner working in the Twin Cities, said the biggest problem with a POLST form from her perspective is the potential for it not to be current with a patient’s changing health care status.
“This is why a prewritten document has its limitations,” said Tawil, who served on the MCC-CHA study committee and is a member of St. Raphael in Crystal. “A designated power of attorney who acts out of Christian love for the patient and is educated in the patent’s current medical situation and . . . the overall burden of illness is crucial to guiding morally sound care.”
The bishops’ statement raises additional concerns about POLST. Among them are:
- The forms might be used for patients who are not terminally ill as a form of assisted suicide or euthanasia.
- The form permits but does not require a patient’s signature (or the signature of a legally designated health care agent), and thus raises concerns about having a patient’s true informed consent for important decisions.
- POLST lacks a conscience clause for health care professionals who may have concerns about medical orders they are asked to fulfill.
In discouraging the use of POLST forms by Catholics and Catholic health care providers, Minnesota’s bishops point to better alternatives, including the Minnesota Catholic Health Care directive and accompanying guide. The directive meets the state’s legal requirements and reflects the Church’s teachings on end-of-life care. (The form and guide can be accessed at http://www.mncc.org/resources/mn-catholic-healthcare-directive-2.)
In “Stewards of the Gift of Life,” the bishops also support the appointment of a health care agent who can speak for a patient and act in his or her best interests. And they call for “renewed efforts to educate the Catholic community and other interested persons in the rich tradition of our Catholic teaching on end-of-life care.”
“We need to start having these conversations with our family members, with our loved ones, as uncomfortable as they may be,” Adkins said. “We need to express our own wishes and make sure that when we are pursuing end-of-life care that it is consistent with our own Catholic faith and objective moral norms.
“And,” he added, “we need to look for people in our lives who can help us make those decisions. Otherwise, we leave our families in a difficult position of trying to discern what our wishes might be or how to handle these things.”
The MCC said a future goal is to develop a resource that lays out in “a more substantive and developed way” a Catholic perspective on end-of-life care that helps people understand the various resources available to them.