Physician's order deemed appropriate for clarifying patient wishes

August 1, 2011

Increasingly, clinicians across the U.S. are using a specific type of physician's order to clarify, in advance of a medical event, people's preferences for receiving life-sustaining treatments including resuscitation and intubation. But some ethicists have wondered whether this tool is compatible with Catholic principles.

During a CHA-hosted webinar this summer, Dr. Susan Nelson described the use of this physician's order, and Fr. John Tuohey explained its congruence with Catholic teaching and care guidelines. Nelson is medical director of senior services for Franciscan Missionaries of Our Lady Health System in Baton Rouge, La., and Fr. Tuohey is regional director of the Providence Center for Health Care Ethics in Portland, Ore. The webinar was titled, "POLST: A Dangerous Development or a Useful Tool?"

Nelson told webinar participants that the Physician's Order for Life-Sustaining Treatments, or POLST, has gained popularity in recent years because other advance planning documents, including living wills and powers of attorney for health care, often fall short when used as practical tools in the clinical arena. Those legal documents are valuable for establishing what people's health care preferences are in a general sense, but, said Nelson, they often are too vague to be used by a clinician making life-and-death decisions during a medical crisis.

The POLST is a medical order signed by the patient and physician that outlines a specific care plan — normally for a patient with an advanced terminal illness, such as lung disease. Virtually all POLST templates ask patients to specify whether they want clinicians to attempt resuscitation in the event of a cardiopulmonary arrest, what interventions they wish to have if they have a pulse and are breathing, what antibiotics they want, whether they want artificially administered nutrition and fluids and what special instructions they would like to convey to clinicians.

Louisiana is among the states that have created a POLST form and encourage its use for patients with life-limiting illnesses, including those people in long-term care facilities and those who are expected to die within a year. The state encourages patients to complete the form in addition to completing their advance directives. Patients or their caregivers keep the form at hand so they can provide it to emergency responders. Some states are creating databases so that the responders can access the POLST in a health crisis or when patients do not have the document at hand.

With POLST emerging as a useful planning document, some ethicists have asked whether it gives patients too much control and autonomy in making decisions about their treatments. Some have questioned whether POLST is compatible with the Ethical and Religious Directives for Catholic Health Care Services.

Fr. Tuohey thinks it is. He said that his analysis leads him to believe that POLST is "a useful tool that allows people who have advanced illness to have a greater voice in the care they receive during a life-threatening medical crisis."

He said that people who wonder about patients having too much autonomy may believe that only God can determine when a person's life ends, and that filling out a POLST form gives the patient too much control in end-of-life decisions. However, Fr. Tuohey said, there is another way to look at God's role in the end of life. "God does not have a stopwatch," he said. "We die when the possibility of sustaining physical life is no longer there. And, God receives us when our life ends."

He said that the ERDs allow for people to give input about the care and treatment they will receive, taking into account the benefits of that treatment versus the burdens, and what is reasonable care and what is not. "We don't have to try to push people beyond reasonable measures," Fr. Tuohey said. "We can palliate them at that final time, and we can help patients make the decisions that will benefit them."

Referring to the Catholic catechism, he said that while Catholic teaching says that life and health are gifts from God, and that people are called upon to care for their health, there is a limit to what people can be reasonably expected to do to achieve this goal. "It's OK to recognize when there is no longer a benefit" to sustaining all forms of treatment, he said. It is ethically proper not to medically intervene in a natural death, he said.

He emphasized that it's not the timing of death — and the patient's input on that timing — that is key. It is the quality of life and recognition of the sanctity of life that are most important.

Fr. Tuohey noted that the Congregation for the Doctrine of the Faith's Declaration on Euthanasia has confirmed that sick people are not called upon to be heroic in enduring burdensome treatments in order to prolong their life. They have the authority to make the decision about how burdensome treatments are as compared with the benefits of that treatment.

"This is not taking authority away from God," Fr. Tuohey said. "It is exercising the authority that God has given us."


Copyright © 2011 by the Catholic Health Association of the United States
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