Posted on 08/28/2011 11:12:55 AM PDT by wagglebee
DENVER, Colorado, AUG. 24, 2011 (Zenit.org ).- A problematic new end-of-life medical form is rapidly gaining ascendency in U.S. healthcare. It is called the "POLST" document. (In my own state of Colorado, it's called a MOST document.) The acronym stands for Physician Orders for Life-Sustaining Treatment. (MOST = "Medical Orders for Scope of Treatment;" its provisions are almost identical across states.) Click here to see an example of a standard POLST document.
The document consolidates on a single form provisions formerly dispersed over several documents: it acts as a living will specifying the scope of medical interventions a patient wishes in case of incapacitation; it makes specific provision for a do-not-resuscitate order (DNR); it has a box to check in the event a patient wishes to refuse treatment with antibiotics; and it allows a patient to designate a proxy decision maker.
Similar to other advanced directives, patients complete the POLST form when their capacities are in tact and the document becomes effective when consciousness is compromised.
But different from older-type directives, the POLST document has provision for the signature of a physician (or physician assistant). This gives the designations on the document the force of an actionable medical order.
The national trend, supported by Compassion & Choices (formerly the Hemlock Society), is to structure state laws on medical directives in accord with the POLST paradigm (as illustrated by its recent adoption by states such as California, Colorado, Hawaii, Idaho, New York, Pennsylvania, Oregon, Tennessee, Utah, Washington, West Virginia and Wisconsin).
Why is the document problematic? I will speak from first-hand knowledge of the legislation that normalized the document in Colorado. I believe my criticisms are relevant to all POLST-type laws in the U.S.
The Colorado law (signed in summer 2010) abrogated an extremely important condition on living wills going back two decades. The former law authorized adults to direct medical professionals to withhold or withdraw life-support only on the condition that they were terminally ill (or in a so-called persistent vegetative state [PVS]). So for purposes of the law the refusal was conditioned by the fact that a patient was already dying. (The PVS provision was accepted under the false assumption that it was a terminal condition.) Forty-five percent of the states in the U.S. presently impose similar statutory limitations on the removal of life-support.
The POLST-type legislation removes the condition that a patient is terminally ill or diagnosed in a PVS before a refusal order is actionable. In other words, the new law permits any adult patient to refuse any treatment at any time for any reason in the event they lack decisional capacity; and health care professionals, directed by a doctor's medical order, ordinarily would be (and are) required to carry out the order. Although the law for strategic purposes is rhetorically formulated as bearing upon end-of-lifemedical decisions, it sets forth no requirement that a patient's refusal of life-support must be limited to end-of-life conditions.
If someone refuses life-support with the specific aim (or intention) of causing his or her own death, the person is choosing suicide. Morally speaking this is no different from ingesting a lethal dose of medication, or sitting in a running car with the windows closed and a hose stretching from the tail pipe to the cabin. "Why are you doing X?" If the answer is: "To die," then the person is intending self-killing, suicide, and that's always wrong.
But isn't it the case that terminally ill patients also can direct the refusal of life-support for purposes of bringing about their deaths? It is true, the condition of terminality does rule out the possibility that patients will be motivated by suicidal intentions when taking advantage of the liberties permitted by the older-type law. But in establishing the refusal of life-support in the context of medical conditions diagnosed as "terminal," the older-type law privileged as the normative context for refusing life-support the motive "to-be-free-from-burdens-in-my-remaining-days-of-life." Suffering from a condition from which one was dying, the law granted a person the civil right to refuse procedures that prolonged the dying process.
This is not the place to rehearse the ethical argument for the legitimate removal of life-support. Suffice it to say that until recently, common ethical opinion accepted the judgment that if some treatment was futile or excessively burdensome, then a person legitimately could refuse the treatment, even if its refusal promised the hastening of death. [Note: the procedure, not the life, is judged burdensome.] One intends to be free of the burden of painful, risky, or futile treatments during one's final days of life, and one accepts that one's death may be hastened as an unintended consequence.
The POLST-type law grants adults the civil right to direct healthcare professionals to remove life-sustaining procedures when those procedures are not futile and when the burden imposed by them would be offset by a reasonable hope of recovery. It juridically extends the ordinary context for the refusal of life-support to include the motive of bringing about death. Without using the term, the new law authorizes euthanasia.
This is not the only problem with the POLST model, but it's the most serious problem that the model introduces. Other problems, such as the document's provision for the removal of food and water from patients for whom they reasonably would be judged to be ordinary/proportionate care, or the simplistic designation, "No Antibiotics," whether or not such drugs are medically indicated, already infect older type documents.
When the Colorado Catholic Conference, which I assisted, was fighting (ultimately unsuccessfully) at the state capital in Denver to amend the POLST-type legislation before passage to reintroduce the condition of terminality, we argued that the legislation as written was effectively legalizing euthanasia by omission. Some legislators believed that we were being alarmist. They thought that because physician-assisted suicide was not legal in Colorado, nor explicitly legalized by the proposed legislation, we had nothing to fear. We said we thought this was short-sighted, that groups like Compassion & Choices would find fertile soil in the law for advancing its aims. Most were unconvinced.
On August 17, 2011, Compassion & Choices (CC) launched a nation-wide public education campaign entitled "Peace at Life's End – Anywhere." The euphemism means "legal self-killing anywhere in the U.S." (The press conference was held in Denver, Colorado!) The central purpose, indeed the sole purpose of the campaign is to tell people everywhere that they can kill themselves legally anywhere in the U.S.; all they've got to do is to refuse life-support, in particular food and water. The Web site reads:
One method of peaceful dying…universally available, legal, safe, painless and suitable for a gentle parting in one's own home…is the purposeful refusal of food and fluids, in medical jargon known as voluntarily stopping eating and drinking (VSED).
"VSED," its press release stated, "is a legally recognized option for mentally competent adults who wish to end their suffering." And best of all, "it requires no special laws or regulations. VSED is legal -- for patients and their caregivers -- today, in every state."
The POLST document is not a precondition for the success of CC's campaign. Any living will that permits the removal of food and water would be adequate. But the new document sure helps.
If the POLST model is not already legally recognized in your state, five to one chance that legislation is being drafted at your state house as we speak. You might call your legislator and find out.
* * *
E. Christian Brugger is a Senior Fellow of Ethics and director of the Fellows Program at the Culture of Life Foundation , and the J. Francis Cardinal Stafford Chair of Moral Theology at St. John Vianney Theological Seminary in Denver, Colorado.
bttt
you get 4 gold stars for your post.
Sadly, many adopt a position of one of two extremes on this subject.
I’m watching a close relative battle cancer right now and rethinking EVERY position I’ve ever had about end-of-life medical decisions.
I believe QUALITY of life is most important.
YEars ago, my grandmother (age 93) was in the hospital and was not expected to live. HEr son and daughter both signed a DNR. She ended up passing in her sleep with me sitting by her side.
No, because declining these things will not for an absolute certainty end a person's life -- declining nutrition and hydration WILL.
As has been often pointed out, some treatments don’t prolong life, they prolong dying.
I fail to see the benefit of that, but I wouldn’t dream of forcing someone to not receive a treatment they want.
By the same token, I don’t believe anyone should be forced to accept any treatment they don’t want.
The author of this piece seems to think such decisions should be left in the hands of doctors. That’s one of the stupidest things I’ve ever heard. Doctors were the biggest proponents of the German euthanasia programs (which started long before the Nazis took power), and today in the Netherlands they essentially have the power of life and death over anybody in a hospital.
So sorry for your loss. FReeper after FReeper have shared their personal end of life stories and the wrenching events and great pain their loved ones suffered.
Inevitable, someone who wasn't their and has no relationship to you will opine how great palliative care works and then suggest it was YOUR fault you couldn't find it. You should have tried harder. And besides don't you know the benefits that can be obtained from great suffering? If you don't appreciate these suffering/pain benefits they will suggest your walk with God needs adjusting.
Then they suggest the state, church or courts are the best places for this to be settled rather than within your family. ~sigh
If "X" = only hand feeding and offering water, I have no problem with your position.
Once "X" turns into TPN and a ventilator, I believe your position is no longer of universal application, but rather requires interpretation for each incident case..
I respect your views, but I have been working with terminally ill people every day for >30 years, and I'm not sure that the principle you are defending is as determinative in all cases as you appear to believe.
Perhaps she has a living will that prohibits a feeding tube or other artificial supports
Do you not agree that a person deprived of food and water will ALWAYS die?
The Judeo-Christian ideal is to protect all innocent life from the moment of conception until natural death.
Death accelerated by dehydration is not natural, its euthanasia.
Certainly, alleviate as much pain as humanly possible with appropriate meds, but food and water are STILL basic human rights, NOT “medical treatments” that can be arbitrarily withdrawn on a whim.
My mother-in-law died two months ago from lung cancer (she never smoked) that had metastasized to her spine, sacrum and pelvis. She had multiple pathological fractures from the mets. That’s one of the most painful causes of death known to modern medicine. But we managed to keep her pain controlled for her, and she died of the lung cancer, not dehydration. We had to fight with the hospice and threaten them to get her proper hydration via IV, but there was no way we were going to let a loved one die the miserable death of dehydration. Besides break through pain, her primary complaint was how dry she felt.
Don’t let ANYONE feed you the lie that dehydration is a good thing, humane, or alleviates suffering. There’s a good reason hospice and pallitive care always couples deliberate dehydration with large doses of morphine. Otherwise those dying of dehydration suffer greatly. Anyone promoting dehydration as an “alternative” to suffering should be locked in an 85degree room at 0% humidity without water for several days to see for themselves just how gleeful it feels.
What you have in italics is true but how you legislate it? How do you stop an intentional overdose? Reducing pain is certainly allowed, even if it may hasten death. Extraordinary treatment is not required even among Catholics (although feeding tubes and nutrition is not considered extraordinary).
In my state, patient advocate forms require two witnesses and takes effect at incapacitation. Some of the specifics I've included in the forms are based on the express wishes of clients. My clients were relatively healthy, and that was reflected in their wishes. They don't want to be in pain the rest of their lives. They want to be independent and not vegetables and hooked to respirators for 20 years. They want to want to recover if they can.
As someone who has practiced as an estate planning attorney, I've dealt with this issue. Most people don't truly understand what "Do not resuscitate" (includes cardiac arrest) or "Pull the plug" (which machines?) means. Now I'm not a Priest, and my job was to advocate for my clients. Part of that was informing them how words mean things and to get them to think about what they are saying, discuss with their families and make informed decisions so I can do my job properly. Most of them aren't in the legal or medical fields. They do know what they want, but don't always know how to say it. That's the danger, and why we all as individuals need to make sure we have patient advocate forms drawn up according to our state guidelines to express our wishes, no more than ever in the era of Obamacare.
Generally, people don't want to be in severe chronic pain. People don't want no hope for recovery. If there's a chance of recovery, most people want to take that chance. They want to be with their families and grandkids.
One of my big fears with Obamacare is what will happen in some cases. My grandmother was 78 when diagnosed with lung cancer. It was terminal and supposed to be six months. Grandma fought it and lived until she was 81. She wanted to live because two more grandkids, and a great grandkid were on the way. She wanted to see me graduate from college. She loved being a grandmother. That all happened in that 3 year period. Is Obamacare going to take that away from my parents in their 60s?
There is no need to rush it. One day, you'll notice you quit.
Fortunately you’re wrong on both counts.
you vill serf da schtate!!!!you vill die for your country!!!
My sincere condolences.
I just got home from the hospital where my pop is but a few hours away from the end. Like the relationship you apparently had with your dad, we are carrying out his expressed desires. There is nothing simple or pleasant about any part of this but my pop was there for me when I needed him and I will be there for him now.
You are a good son.
Not unless she signed one while she was in the hospital 2 weeks ago
They brought her all the trays while she was there..
granted they were trays of food but isnt an IV drip the same in a way ???
Well today it dawned on my lightning quick mind...
They are uping her morphine constantly because her starving body is gradually in more pain..
Its not the camcer that is hourly causing her so much more pain
Her body is hungry and thirsty...and suffering deprivation..
HELLO ???
Thank you Dr for your medical input...
I agree with you...
Frikkin unbelievable! I hope your parents will file a formal complaint with the Joint Commission, and with the board of the hospital.
always couples deliberate dehydration with large doses of morphine. Otherwise those dying of dehydration suffer greatly.
___________________________________________
Yeppers they keep upping the dose...
She has a tube running into her chest and the little portable thingy..
The woman is still lucid and holding conversations ..
She says she wants to live...
I can tell you that according to the doctrines of the Catholic Church, which are extremely well-defined and carefully developed over centuries regarding life issues, that in this particular case that was NOT murder and NOT suicide.
I can explain the whole rationale, but not sure you care about the theology. Just thought I could comfort you a bit that from a Christian perspective anyway, the doctor who administered the morphine as a treatment for pain, which had the possible side effect of death, was acting responsibly. Murder was NOT the intention, he was giving medical care; if that care hastens death as a “side effect” as it were, it is not wrong.
Thank you. I know that my ex-wifes’ family has always considered what he did to be an act of merciful kindness.
It will only fly with the people if and only if the public sector employees and every member of congress & senate & executive & judicial are forced to sign this contract as part of employment.NO EXEMPTIONS ON THE TAXPAYER PAID EMPLOYEES. This includes their families ( children ) if these benefits are publicly funded.
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