This white paper, prepared by a working group of the Catholic Medical Association, provides a commentary on a new type of end-of-life document called a POLST form (Physician Orders for Life-Sustaining Treatment) as well as on its model (or “paradigm”) for implementation across the United States. After an introductory section reviewing the origin, goals, and standard defenses of the POLST paradigm and form, the paper offers a critical analysis of POLST, including an analysis of the risks that POLST poses to sound clinical and ethical decision-making. The paper ends with several commendations to help Catholic healthcare professionals and institutions better address the challenges of end-of-life care with alternatives to POLST.
Keywords: POLST, End of life care, Living will, Advance directive, Advance decision-making, In-the-moment-of-need medical decision-making, Euthanasia, Catholic health care.
INTRODCUTION: The Challenge of Ethical Decision-Making at the End of Life An attitudinal shift has taken place in the past half-century in the culture of end-of-life (EOL) care. The ancient and ineradicable fear of death has begun to live uncomfortably along side a waxing fear of living too long, of being a burden to one’s caregivers and of languishing meaninglessly in debility, dementia, or terminal demise. Many factors account for this shift, but three seem most significant. First, the development of medical technologies and better health measures since World War II have meant that elderly people are living longer, which means more are living into a period of dementia frequently spending their final years in institutions away from their families and loved ones. Second, the loss of Christian faith has meant that people’s thoughts on suffering, old age, and dying are decreasingly characterized by a sense of divine judgment (i.e. of a hope for heaven and desire to avoid hell), of the Christian meaning of suffering, and of the intrinsic value of human life. Finally, the weakening of our bonds of community has meant that more elderly experience loneliness and alienation when the measurable utility of their daily activities naturally decreases. One prominent American bioethicist writes: “many of us now worry that death will come too late—long after life has lost its usefulness and its savor, long after we have ceased to have a ‘life,’ perhaps long after we are even ourselves” (Hardwig 2009, 38). Consequently, more and more people are feeling an urgent need to control the conditions surrounding their own deaths in order to avoid what they believe may be “a death that comes too slowly and too late” (Hardwig 2009, 38).
The frenzied search to find a means to provide for a death without pain is promulgated by many religious, political and medical leaders in society. Health care professionals and others often fall into the trap of inadvertently degrading the human dignity of death by attempting to block consciousness of the dying experience both in the dying person and in those observing the death process. Newer methods of dealing with the pain of death often provide a provisional pseudo comfort which masks the actual experience that the person is going through. Painless death is not always possible and the reasons for that are sometimes ignored.