By BRIAN CLOWES
(Editor’s Note: Brian Clowes has been director of research and training at Human Life International since 1995. For an electronic copy of chapter 23 of The Facts of Life, “Euthanasia,” e-mail him at bclowes@hli.org.)
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We have seen that there are many problems associated with the standard Living Will, although these are not insurmountable with the assistance of a qualified attorney. Fortunately, there are alternatives to the Living Will that allow a person to transfer his medical decision-making to another who shares his values regarding human life, thus giving him a much larger degree of protection. There are also certain types of alternative advance directives that should be avoided.
Alternatives to the Living Will. There are many different types of Advance Medical Directives besides the Living Will, which is currently the most popular version. Unlike most Living Wills, these Durable Powers of Attorney (DPAs) or hybrid documents do not require that the signer suffer from a terminal condition.
A person signing a DPA should take great care that his surrogate or proxy shares his values regarding human life and end-of-life issues. Catholics should ask those individuals who know and respect the Church’s teachings regarding end-of-life care to be their surrogate decision-maker. These surrogates should also know them and their values well enough to competently represent them. After all, the signer is giving the proxy great power to determine what medical treatments will and will not be provided in the case that the signer becomes unconscious or incapacitated.
The POLST. One type of medical directive is the POLST (Physician Orders for Life-Sustaining Treatment), which is not an advance directive. It is an actual order that empowers the attending health-care professional to do exactly what is written on the document. This means that if the patient or his surrogate wrote a POLST indicating a desire for the cessation of various treatments (nutrition, hydration, antibiotics, and resuscitation) under certain specified conditions and signed this document, it would be obeyed by the physician to whom it is presented.
For example, if the patient is transferred from his own home or from a nursing home to a hospital emergency department for an acute medical problem, the ER physician will follow these orders exactly, without first discussing them with family members or surrogates. The POLST was initially proposed for patients who are likely to die within one year. But many nursing homes require POLSTs to be filled out upon admission, even if the patient is not likely to die within a year.
This highlights an important practical and moral problem with POLSTs. To make informed moral decisions, the health circumstances of the patient are an important factor in determining whether the medical decisions made are good or evil. Patients who are not imminently dying are not usually in a position to make an informed and moral decision as to what means to preserve their lives are ordinary (and morally obligatory) or extraordinary (morally optional).
POLSTs are legally optional, and nursing facilities cannot force anyone to fill one out, nor can they threaten a patient with denying admission to their facility if they do not have a POLST.
In addition to patients not knowing the full medical circumstances that they are being forced to make decisions about, there are other problems associated with POLSTs. They may favor the option of non-treatment. They compel medical professionals to follow them (since they are legally binding physician’s orders), even over the objections of proxies. In some states, the signature of the patient or his proxy is not required, leading to the possibility of the form being placed in the patient’s medical record without his knowledge or consent. Finally, in certain cases, medical professionals can use POLSTs to manipulate patients, leading them to be euthanized.
Additionally, several studies of thousands of patients have shown that POLSTs do not improve quality of care and do not extend the life spans of those who signed them.
Durable Powers of Attorney (DPAs). A Durable Power of Attorney for Health Care (DPA), sometimes called a Health Care Proxy, simply transfers the responsibility for making medical decisions from the patient to another person when the patient becomes unable to make his own decisions. A DPA allows the person they’ve appointed to become the patient’s “attorney in fact.”
Ideally this person will be someone who knows the Church’s teachings and shares his values regarding the sanctity of human life. The designated person need not be an actual attorney or health-care worker — he or she may be a spouse, relative, priest, rabbi, or minister, or fellow churchgoer.
A person who selects another to be the executor of a DPA should be certain that he has thoroughly discussed his wishes with the executor regarding medical care should he become incapacitated (these instructions should be detailed enough so that the person executing the DPA can infer decisions regarding medical treatments that are not specifically discussed), and that the executor will be available and capable of making proper decisions under stress.
A DPA is very much preferable to a Living Will, because the latter is a static document that simply cannot cover all possible contingencies, and it may be interpreted incorrectly by someone who does not share the patient’s values regarding the dignity of human life.
The Pro-Life DPA. Some pro-life groups have drawn up model Durable Powers of Attorney that serve as pro-life alternatives to the Living Will.
These Pro-Life DPAs do several things:
They define euthanasia precisely and explicitly prohibit it;
They define food and water as basic treatment, and allow a person to specify those medical treatments that he would want withheld or withdrawn under certain circumstances; and
They specify that attending health-care workers must do what they can to preserve the person’s life “without discrimination based on age or physical or mental disability or the `quality’ of life,” and prohibit “any action or omission that is intended to cause or hasten death.”
The Pro-Life DPA is a realistic and protective alternative for a person who rejects the utilitarianism of the Living Will and who does not want to place the burden of life or death decisions on a loved one or friend.
There are currently several explicitly pro-life Advance Medical Directives. The following groups provide detailed information on end-of-life decisions and all aspects of euthanasia and physician-assisted suicide from a pro-life perspective.
One AMD that you can be certain will respect your wishes and will be in accord with authentic Catholic teachings is provided by the National Catholic Bioethics Center. It is included in the NCBC’s “A Catholic Guide to End-of-Life Decisions,” which can be ordered in print or electronic format at www.ncbcenter.org/publications/end-life-guide/.
If you or your proxy have any questions, the NCBC offers consultations for a small fee.
A Patient Self-Protection Document (PSPD) is on the website of the Hospice Patients Alliance (HPA) at www.hospicepatients.org/patient-self-protection-document-from-illinois-rt-to-life.html.
A Protective Medical Decisions Document (PMDD) may be obtained from the Patients Rights Council (PRC, formerly the International Anti-Euthanasia Task Force) at: www.patientsrightscouncil.org/ site/advance-directive-protective-medical-decisions-document/.
A Will to Live may be obtained from the Will to Live Project, a project of the National Right to Life Committee, at www.nrlc.org/medethics/willtolive/states/.
The Pro-Life Committee of the United States Conference of Catholic Bishops has published a pamphlet entitled “Advance Medical Directives: Planning for Your Future,” which provides general guidelines for those considering such documents. To download it, visit the USCCB website and search for it.
Keep in mind that any competent attorney can draw up a custom-tailored Pro-Life DPA if you request him to do so. First, make certain that he is a lawyer who values human life as God intended. If he does not have a lot of experience with DPAs, he may want to order a copy of one of the above documents as a starting point and modify it there according to your wishes.
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