Life a Path, Death a Destination

“Death is just another path, one that we all must take,” the wizard Gandalf says in J.R.R. Tolkien’s Return of the King. He is right – sooner or later, everyone faces death – but the path leading there can look very different depending on one’s circumstances at the end of life. Modern medical advances can now often prolong old age through illness and enfeeblement, but at what point should human mortality be embraced, facing death with dignity?

In 2012, the Georgia General Assembly passed a bill initiating a medical form called Physician Orders for Life-Sustaining Treatment, or POLST, intended to help patients in their final year of life face these questions and communicate their answers to doctors and healthcare providers. This year that amended law – passed by both houses of the legislature and now awaiting the governor’s signature – sets down many more specifics on how this law is implemented and opens up some serious concerns.

In a nutshell, the POLST form was designed to translate a person’s wishes regarding what kinds of medical care he or she wishes to receive during the last year of life into medical orders a doctor or first responder can easily recognize and implement across treatment settings.

As with any end-of-life care issue, Georgians who support Personhood need to understand the potential benefits and problems presented by this relatively new medical idea. The standardized, one-size-fits-all approach of POLST has several problems in addition to the benefits asserted by its advocates. And when the process concerns potentially life-saving medical procedures, those problems become critical.

Several pro-life organizations across the nation have criticized the POLST model for its cookie-cutter approach to end-of-life care as well as its potential to facilitate quick, “convenient” death, possibly even contrary to what a patient truly desires. In July 2012, the five Catholic bishops from the state of Wisconsin released a pastoral statement warning of POLST’s oversimplification of complex medical decisions that should only occur after all factors are known, such as the potential benefits, expected outcomes, and risks or burdens of the treatment.

“A POLST oversimplifies these decisions and bears the real risk that an indication may be made on it to withhold a treatment that, in particular circumstances, might be an act of euthanasia,” reads the statement. “Despite the possible benefits of these documents, this risk is too grave to be acceptable.”

More than 25 states have adopted some version of the POLST form (though sometimes called by other names such as MOLST, COLST, or MOST), but how well they serve their intended purpose varies widely according to state law, variations on the forms themselves, and the practices of doctors and healthcare administrators in charge of implementing them.

But why does Georgia need POLST when other advance directive measures, such as Durable Power of Attorney for Health Care (DPAHC), already exist and remain in widespread use? The chief advantage of a POLST form is supposed to be convenience and understandability for the physician, first responder, or other healthcare providers – especially as the patient transitions across healthcare settings, such as from hospital to hospice or vice versa.

Advance directives are designed to guide an attending physician, and a person designated as a patient’s DPAHC can certainly make informed and personal decisions for a patient – but in a crisis situation, standardized medical orders provide easily-executable treatment options where it may take time to look up a patient’s advance directive or contact his or her DPAHC. A POLST form that accurately reflects a patient’s wishes could help doctors follow a treatment plan consistent with the patient's wishes.

Georgia’s POLST form (which closely resembles the national model) essentially comprises a series of categories describing several types of emergency care and life-sustaining procedures, with checkboxes through which a physician can indicate his or her patient’s wishes regarding those procedures. The first category indicates whether or not a patient wishes to receive cardiopulmonary resuscitation (CPR) if having a heart attack.

The second category allows a patient to choose whether he or she wants to receive full treatment for injuries and illnesses (including mechanical ventilation, electric defibrillation, etc.), comfort measures only (relieving pain and suffering through medication or wound care without treating the cause), or some level in between.

Another section indicates under what circumstances a patient wishes to receive antibiotics in order to sustain his or her life.

A fourth section specifies whether a patient wishes to receive artificial nutrition and/or fluids, via a feeding tube or IV.

In theory, these medical orders can guide attending physicians and first responders when determining how to treat a patient in a crisis situation in according to his or her previously-discussed wishes. However, even if a physician does work closely with his or her patient to explain and fill out the form, POLST places the lion’s share of responsibility on the doctor, not the patient – both to explain what all the choices mean and to accurately “translate” the patient’s wishes onto the form. Some states’ versions of the POLST form, such as New Jersey’s, do not even require the patient’s signature in order to take effect. (The amended Georgia law does.)

Elizabeth Wickham, Executive Director of nonprofit educational ministry LifeTree, wrote that a patient’s physician usually has a minimal role in working with the patient to fill out the POLST form, the job instead often going to specially-trained “POLST facilitators” (often social workers, chaplains, or hospital administrators). Wickham said the goal is “to steer patients into checking boxes which would limit medical treatment” – in effect, expediting death, regardless of what the patient would actually prefer.

In Georgia, the law does require a patient’s signature. It is troubling, however, that a POLST form that differs from a patient’s previously-enacted advance directives (including a DPAHC) would override those older directives. While intended to allow a patient to adapt his or her desired care to changing physical conditions, this presents the possibility of a confused or depressed patient making choices about future care that he or she does not really want – and those choices superseding decisions previously discussed and agreed upon with their loved ones. Or, if a patient with an advance directive becomes incapacitated, a family member might be able to make choices on a POLST form that conflict with what the patient already decided regarding end-of-life care, and the POLST would control.

Other problematic aspects of Georgia’s POLST policy include:

  • It is still a standardized set of checkboxes with limited options to control what are often intensely personal, individualized decisions concerning a person's health at the end of life.
  • It requires that other states’ POLST forms that are “substantially similar” to Georgia’s be recognized here (although such out-of-state forms must still contain the signature of a patient or authorized representative), possibly forcing medical personnel to administer or withhold treatments that Georgia’s version does not allow.
  • It still treats food and hydration as “treatment” that is able, per the wishes of a patient or his/her representative, to be withheld like medicine – a troubling ethical concept that could allow for assisted suicide under the guise of “end-of-life care.”

From a broader perspective, how a policy like POLST gets implemented really depends upon who administrates it. Unfortunately, the prevailing philosophy regarding end-of-life care in the medical community at large – particularly the higher levels of administration and policymakers – seems to be that once a person has lived a certain amount of their life, they ought not “take up resources” that could better serve younger people with more life left. This philosophy runs squarely counter to the principle of Personhood. But medical policies such as the POLST model can easily create enormous pressure for healthcare administrators to encourage “expedited death” to get the dying process over faster and more “conveniently,” for either the patient or the loved ones involved.

No foolproof legal method exists to prevent this entirely. No law can completely counter a culture that views human beings as expendable utilities. But measures such as a durable power of attorney for healthcare can at least require that trusted loved ones be involved in the process of making medical decisions, instead of reducing that process to a series of checkboxes. Even advance directives are more complex and encourage more reflection by patients and physicians when preparing and implementing them.

Death comes to everyone; it is a natural part of this physical, earth-bound life created by God. Rather than recoil from death and seek to either unnecessarily prolong it or to hasten it for the so-called good of "society’s convenience,” Christians ought to come to terms with physical death and prepare for it accordingly.

The principle of Personhood demands that we affirm and protect the inherent dignity of every human life, including providing life-saving medical treatment except when that treatment unnecessarily prolongs natural death.

The Christian pro-life community ought to focus on providing intentional, loving care for all, including those at the end of life. Medical technologies and policies that promote this care should be embraced, while those that simply seek to make dying more expeditious – getting it over quickly – must be discarded.

For more information on how to set up a DPAHC, click here. For more information on end-of-life issues, browse GRTL’s educational resources on this topic.

By Jonathan Arena
Guest Journalist, Pillars of Personhood Peer Leader