Precaution should precede POLST consent

You’ve just arrived at the emergency room after receiving a call that your elderly mother has suffered a mild stroke. After being assured she’s not in immediate danger, you are handed paperwork including a form marked “POLST.” You ask what it is, and a hospital representative tells you that a nurse will meet with you and your mother in the next 24 hours to complete it.

POLST stands for Physician Orders for Life Sustaining Care ¹ — an actionable medical order

Joe Zalot

signed by a certified clinician documenting what treatments a patient chooses to receive, and not receive, at the end of his life. In most states, POLST is either a legally recognized medical form or efforts are underway to make it such. Many people support POLST because (a) it fosters shared decision-making between patients and their physicians, (b) it offers patients a medically actionable means to assure that their treatment wishes are respected, and (c) it encourages advance-care planning conversations between patients and their loved ones. While POLST can be used for good ends, there are serious concerns with it as well. Here are three ethical challenges that you or a loved one need to consider before completing a POLST.

1) Informed consent is essential to health care decision-making. In order to properly consent to a medical treatment, one has to know what one’s condition is, the prognosis, the available treatment options, as well as the benefits and risks of each option. Unfortunately, POLST can undermine informed consent because in completing the form one is making treatment decisions about a future medical condition for which one has only limited (if any) knowledge. Stated differently, the future-looking POLST offers no guarantee that a patient’s consent to treatment (or non-treatment) will be informed by the concrete circumstances of their medical condition at the time a decision needs to be made. In response, it is important for a patient (or proxy) to know that he can alter or revoke a POLST at any time to meet changing medical conditions or treatment preferences. Make sure that language indicating how to alter or revoke the order is plainly visible on the form itself before you complete it.

2) For whom is a POLST appropriate? The National POLST Paradigm Task Force states that POLST is appropriate for patients “with serious illness or frailty, whose health care professional would not be surprised if the patient died within one year.” This language should raise a number of red flags. “Serious illness” and “frailty” are never defined on a POLST form, and no guidance is offered for how to apply these terms in a clinical setting – other than the clinician “would not be surprised” if the patient died as a result of them within the next 12 months. The ambiguous language utilized by POLST is highly problematic, as it inevitably leads to confusion and possibly even abuse. In actuality, a POLST is only appropriate for a patient who has been diagnosed with a terminal illness, defined as having less than six months to live.

3) A third concern with POLST is that it can allow patients and physicians to create a medical order which violates Catholic teaching. The primary example of this is that POLST allows patients to refuse nutrition and hydration in any situation and for any reason. Nutrition and hydration, even when delivered by medically wassisted means, are, in principle, basic human care and thus morally obligatory (with some rare exceptions). POLST undermines this teaching. It also places Catholic clinicians in the unenviable situation of either following a medical order and violating their own consciences, or exercising their right to conscience and risk being sued or “summoned for a talk” with their licensing board. In response, patients should indicate on a POLST form that they want nutrition and hydration to be provided by any means until such time it is medically determined they no longer receive benefit from it.

Remember:
• You (or a loved one) are under no obligation to complete a POLST form.
• Ask questions to get the POLST directives clarified.
• Seek guidance regarding the Church’s teachings on end-of-life decisions.
• Speak with your loved one – learn his or her treatment wishes, then only use POLST as a means to document those wishes.

JOE ZALOT is a staff ethicist with the National Catholic Bioethics Center in Philadelphia. He earned his Ph.D. at Marquette University, and has worked in Catholic higher education and health care.

¹Some states use MOLST (Medical Orders for Life Sustaining Care), POST (Physician Orders for Scope of Treatment), or other variations.