Tag Archives: end-of-life issues

Navigating ethical quandaries of end-of-life care

Bioethics focuses increasingly on end-of-life concerns. The incredible advances in science and medicine help people to live longer lives, but also present many ethical dilemmas as death approaches. There is a dizzying array of medical options at the end of life.

The chief ethical question is not what medicine can do, but what it should do in a concrete case. Fully 40 percent of the individual consultations that come to us at The National Catholic Bioethics Center (NCBC) concern end-of-life decision making. People have genuine and understandable ethical quandaries when it comes to advanced directives or deciding what is ordinary care, and therefore morally obligatory, or morally optional extraordinary treatments.

One of the most popular publications of the NCBC is our Catholic Guide to End-of-Life Decisions. I think it is safe to say that almost everyone will be confronted with end-of-life decision making for themselves or a loved one at some point. This is where some knowledge of bioethics becomes a necessity. This compact document, or others produced by dioceses or other faithful Catholic organizations, can be a great guide through dangerous pitfalls at the end of life.

The NCBC strongly urges individuals to consider appointing a health care proxy as opposed to other kinds of advanced directives. If the person chosen has a strong Catholic faith and understands the wishes of the person they will be serving, this is a morally sound choice.

Why are ’living wills’ or Physician Orders for Life-Sustaining Treatment (POLST forms) not a better option? Space limitations here do not allow for a full treatment of this topic, but here is a summary of our reasons. It is impossible to know in advance what decision should be made in every possible future medical scenario. Furthermore, a person’s views will almost certainly change over time, but unless the living will or POLST form is changed, those directives will remain in place. The best moral medical decision making happens in the moment when the current circumstances are known. This is possible with a health care proxy or agent, but not with other kinds of advanced directives.

There is also a danger with advanced directives that elements contrary to Catholic teaching may be included, for example, improper withdrawal of nutrition and hydration. The Congregation for the Doctrine of the Faith clearly stated that this is ordinary care in the vast majority of cases. The only exceptions that could apply are: if the person’s body can no longer assimilate food or water; it is excessively burdensome; or the dying process has actively begun. The Church does not want anyone to die of dehydration or starvation. This is a passive form of euthanasia and is, sadly, becoming more common. Some people end their days by Voluntary Stopping of Eating and Drinking (VSED). This practice is clearly unethical and condemned by the Church.

The most important moment of our entire existence is the end of our earthly life. Our eternal destiny is determined at death. Up until our last breath we can choose God or turn away from Him. A deathbed conversion can rescue a person from Hell. Final despair can deprive us of God forever. It is therefore vital that we make the right moral decisions as death approaches. The NCBC is a resource for Catholics in this area with our free counseling given by trained ethicists. Go to www.ncbcenter.org to reach our counseling service or to get a copy, for a small charge, of the NCBC end-of-life guide.

DR. JOSEPH MEANEY, president of the National Catholic Bioethics Center, earned a Ph.D. in bioethics from the Catholic University of the Sacred Heart in Rome. Formerly, he was director of international outreach and expansion for Human Life International (HLI). He has travelled to 81 countries on pro-life missions over 25 years. He has been featured internationally via his writings and broadcast appearances.

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.