Chief Executive Officer
Minnesota Medical Association Foundation
3433 Broadway Street NE, Suite 187
Minneapolis, MN 55413
Dear Ms. Gloege:
Thank you for the opportunity to comment on the changes to the description of the MMA POLST form, specifically, the proposal to expand its usage from patients with “advanced serious illness” and terminally ill to those “in the last years of life” or to those who would choose to complete a POLST.
In short, there are serious potential risks to the exercise of patient autonomy through informed consent related to these linguistic changes about the use of POLST. The proposed expansion of POLST would result in a seismic shift of the original intention of advance medical orders that improve care by eliminating unnecessary interventions. This step would change the focus of POLST from objective medical indications guiding care to subjective preferences for a life plan, and deeply impact the role of providers in caring for those they serve professionally.
We recognize that POLST forms are considered a useful tool by providers because they make patient preferences clear within an easy-to-use form, and in a vernacular that is recognized across systems and by individual professionals. When the Catholic bishops of Minnesota commented in 2012 upon an earlier version of the form, there was a legitimate difference of opinion with the MMA about the potential benefits of the tool versus the associated risks that it would entail. The Catholic bishops discouraged its use and adoption by providers, in part because of specific problems with the form itself (some of which have been corrected, such as the requirement of the signature of the patient or the patient’s surrogate decision maker).
The deeper concern, however, was with the POLST paradigm itself: that healthcare decisions could be made in the abstract by checking broad boxes removed from the actual context of a treatment scenario. Certainly, physicians can be aided when they have clear direction about whether to revive or treat a patient in a certain manner. And the ability of patients to give more specific direction than the typical healthcare directive allows about their wishes related to resuscitation and treatment, and while they have the mental capacity to offer those directions, makes sense in cases of advanced age and illness.
Recognizing the usefulness of some guiding medical order in a particular, and very limited, care context is why the bishops proposed an outpatient DNR/DNI form as a useful, ethical alternative to POLST, along with a strong encouragement for people to identify healthcare agents who could make decisions for them.
Whereas there could be legitimate differences of opinion about the usefulness of POLST related to its risks within a specific subset of the patient population (the very elderly and very infirm at the end of life), the proposed changes underscore why the POLST paradigm presents both a danger to patients and heightens the risk of unethical practices by providers, such as euthanasia or assisted suicide.
1) The most blatant problem with the new language is the expansion of the POLST model far beyond the original (and, even then, questionable) population of patient with “life expectancy of less than a year” and with a life-ending disease condition in active progress. Most simply, perhaps, from an ethical standpoint, the shift moves POLST from (a) decisions about accepting or declining demonstrably extraordinary/disproportionate means to prolong life, to (b) proactively accepting or declining potentially ordinary means to preserve life. It is clearly a move from making decisions rooted in clinical indications to those rooted in individual preferences.
2) A related concern is the separation between the actual situation of the individual patient assessed by informed clinical judgment and met with informed consent, and the application of an abstract and perhaps clinically inappropriate treatment plan made in advance of any such assessment. The reality is that many POLST forms are completed as intake forms in assisted living centers, and not by the person’s primary care provider.
3) It is worth repeating that law, policy, and practice already allow patients the options to exercise control over treatment decisions. The expansion of POLST does nothing to increase this exercise of patient autonomy but rather compromises it.
4) The statement about controlling care “in their last years of life” is disingenuous; the choice to refuse ordinary means to sustain life and health becomes a self-fulfilling prophecy.
5) The signature of a licensed provider is also problematic if that provider does not know the patient or assess adequately the current clinical realities, or if the POLST form can be applied by a different attending physician than the original provider. It is an empty illusion of patient protection.
6) Whereas at the very end of life, a patient’s lifetime is limited, and the scope of potential personal choices and opportunities narrows, that is not the case outside of that context, even in the “last years of life.” A healthy elderly patient checking a DNR box or a narrower treatment plan without conceiving of the many contexts in which the POLST form could be referenced by a physician is highly imprudent and risks denying informed consent to the patient. Offering these forms to patients outside of a very narrow care context borders on malpractice. Based on these concerns, we would encourage you to abandon efforts to expand the use of POLST. The decision to refuse care may make sense in the abstract, but can be unwise in practice, and especially when a patient has the opportunity to connect with loved ones one last time and misses it, or because he or she could not imagine all the care context in which the POLST form could be used.
We acknowledge that, in the minds of many providers, the POLST form is “working.” If it is working for some, leave it be, and avoid turning it into something beyond which it was originally intended.
We welcome the opportunity to converse with you about these concerns in more detail. Thank you for your consideration.
Minnesota Catholic Conference
Thomas (“Toby”) Pearson
Catholic Health Association—Minnesota