Posted on July 19, 2013 at 2:53 PM
Thaddeus Mason Pope, JD PhD
The Physician Orders for Life-Sustaining Treatment (POLST) program is proving to be a highly effective mechanism for assuring that the life-sustaining treatment seriously ill patients want is the same treatment those patients get. A number of scientifically rigorous studies have demonstrated POLST’s material benefits. And a growing number of states have been adopting POLST through legislation, regulation, or clinical consensus. But despite this notable quality improvement, a number of Catholic leaders and organizations have called on Catholic healthcare facilities to “not accept POLST forms and to decline to participate in POLST programs.”
POLST is a tool for translating patient’s goals of care into medical orders so that they are easily located and portable across care settings. POLST is not just a specific set of medical orders documented on a bright, colorful form. It is also an approach to end-of-life planning based on conversations between patients, loved ones, and medical professionals. The POLST Paradigm is designed to ensure that seriously ill patients can choose the treatments they want and that their wishes are honored by medical providers.
But there has been significant protest from Catholic leaders. First, Catholic Bishops in a number of states, like Minnesota and Wisconsin, have issued statements expressing concerns with POLST. Second, similar calls to reject POLST were issued by organizations like the National Catholic Bioethics Center. Then, most recently, the Catholic Medical Association, the largest association of Catholic individuals in health care, published a scathing attack on POLST. (One-half of the CMA working group is composed of members from Minnesota and Wisconsin.) The Catholic backlash is hardly monolithic. Many U.S. Catholic healthcare leaders support POLST. But the opposition is substantial and seems to be growing.
CMA argues that using POLST presents “unacceptable risks.” CMA articulates a number of concerns, but the main one seems to be that POLST is not limited to individuals with a terminal illness. Therefore, CMA argues, patients are making decisions about life-sustaining treatment outside the context of their “present situation.” But this is a serious overstatement. POLST is indicated only for patients with serious advanced illnesses.
The general guidance is that the POLST form is only for seriously ill patients for whom their physicians would not be surprised if they died in the next year. Admittedly, this sort of prognostication is imprecise. Many patients expected to die within the next year do not. POLST embodies patient decisions and medical orders far closer to the patient’s present circumstances than an advance directive. But the decisions and orders are still made in advance.
That seems to be the core of CMA’s problem. They oppose not only POLST but also traditional instructional advance directives, because both embody treatment decisions that are made ahead-of-time, not “in the moment.” Therefore, whatever benefits POLST might offer, CMA argues, will be “grossly outweighed by the harms and abuses.” CMA urges that POLST be “phased out” and replaced with a better alternative.
If only CMA had actually offered one. CMA suggests that POLST be replaced with surrogate decision making. Indeed, this has been famously and cogently argued in the context of advance directives: focus on appointing and talking with your agent instead of on leaving specific directions in a living will.
But this argument does not work with POLST. First, the treatment decisions are far more informed by the patient’s already known and present circumstances. Second, as a set of medical orders, POLST is immediately implementable precisely because neither the patient nor her surrogate may be reasonable available for consent at the relevant time. Indeed, surrogates (not just patients as with advance directives) complete POLSTs for precisely this reason. Third, a virtual deluge of RCT studies shows that surrogates are frequently and wildly inaccurate when making decisions about life-sustaining treatment. If CMA is worried about the accuracy of POLST, they should be even more worried about the accuracy of surrogates. At the very least, CMA should demonstrate (rather than surmise) that surrogates both could and would make better decisions than POLST for the population for whom POLST is intended.
The Catholic opposition has already slowed the development of POLST in some states like Wisconsin. And its effects could be far more widespread. Catholic health care facilities care for nearly one-sixth of all U.S. hospital patients each year. The 620 Catholic hospitals across the United States make up 13 percent of the nation’s 5000 community hospitals. Plus, there are more than 1400 additional U.S. Catholic long-term and other health care facilities.
POLST is not perfect. But, to paraphrase Winston Churchill, it is better than all the other end-of-life healthcare decisions instruments that have been tried before.