POLST of Oregon moves to NC and other states
Elizabeth D. Wickham, Ph.D.
Executive Director, LifeTree, Inc.
March 12, 2006
I attended a meeting at the North Carolina Medical Society
of the task force working to implement a new form into
the normal healthcare routine. It is called the Physician
Orders for Scope of Treatment (POST)
or the Physician Order for Life Sustaining Treatment
The form is presented as a solution to what is described
as a problem of discontinuity of decision making with
respect to the patient's wishes, especially when a patient
is transferred from one facility to another.
The POST/POLST form represents a major change
in the medical routine. Doctors we talked
to say this form will result in less
communication between physician and patient
and mitigate the physician’s responsibility to
communicate with his patient.
The POST/POLST form is a "glide path"
to euthanasia. The POST/POLST
form extends the Do Not Resuscitate order into orders
about medical treatment, antibiotics, and IV fluids/artificial
Nutrition and Hydration (ANH).
Below the section on the POST/POLST form about whether
or not to resuscitate, this form offers three levels
of choice: 1) whether to receive comfort measures only,
limited medical treatment, or the full scope of medical
treatment with transportation to the hospital; 2) whether
to receive no antibiotics, limited use of antibiotics
or antibiotics (if life can be prolonged); and 3) whether
to use no artificial nutrition and hydration (ANH) and/or
IV fluids, ANH and/or IV fluids for a trial period,
or ANH and/or IV fluids long term.
The POST/POLST form builds on the incorrect premise
that a person has an unqualified right to refuse any
The Catholic Church teaches that because life is a
gift from God we have a primary obligation to show reverence
for it at all times, from conception or cloning to natural
By euthanasia is meant an action or omission that of
itself or by intention causes death. No one should
be deprived of basic care. No physician
or health care professional should encourage a patient
to violate his moral obligations.
The process of creating a form such as this is based
on a faulty premise of complete autonomy. The
Church teaches that medical treatment, medication, and
procedures that offer reasonable hope to protect and
preserve life without grave burden to oneself or another
are ordinary care.
We quote from the Charter for Health Care Workers –
Pontifical Council for Pastoral Assistance to Health
Care Workers (http://www.wf-f.org/healthcarecharter.html):
64. The health care worker who cannot effect a cure
must never cease to treat. He is bound to apply
all “proportionate” remedies. But
there is no obligation to apply “disproportionate”
In relation to the conditions of a patient, those
remedies must be considered ordinary where there is
due proportion between the means used and the end
intended. Where this proportion does not exist,
the remedies are to be considered extraordinary.
To verify and establish whether there is due proportion
in a particular case, “the means should be well
evaluated by comparing the type of therapy, the degree
of difficulty and risk involved, the necessary expenses
and the possibility of application, with the result
that can be expected, taking into account the conditions
of the patient and his physical and moral powers.
(Cong. Doct. Faith, Declaration on Euthanasia,
May 5, 1980, in AAS 72 (1980 p. 549).”
The POST process itself is flawed. The form is filled
out during a patient interview conducted by a health
care professional such as a nurse, nurse practitioner,
social worker, admissions coordinator or nursing home
administrator. They go over the form with the patient
and help him pick the boxes to check in cafeteria fashion.
These health care professionals are trained in the
Respecting Choices curriculum of La Crosse, Wisconsin
to become certified Advance Care Planning Instructors.
Especially worrisome is that the Respecting
Choices Program teaches the interviewer a theoretical
framework with which to effect change of the patient’s
"During this discussion, the status of existing beliefs
that are barriers to effective coping can be mitigated
by explicitly discussing the limitations, or consequences,
of adhering to and acting on those beliefs." (See p.3
of article by Linda Briggs, RN, entitled “Shifting
the Focus of Advance Care Planning: Using an In-depth
Interview to Build and Strengthen Relationships”.
Training for the facilitators who would guide the patients
in doing the NC POST forms is provided by The Carolinas
Center for Hospice and End of Life Care, the same group
that organized the Rallying Points Summit in 2003 which
featured the lawyer for Nancy Cruzan's family, Bill
There was much discussion at the NC Medical Society
meeting about who signs the form and which signature
is mandatory. NEITHER THE PATIENT NOR
HIS REPRESENTATIVE IS REQUIRED TO SIGN. The
only required signature is that of some physician, any
physician. The physician who signs may or may not have
been present when the patient interview took place,
may or may not even know the patient.
In view of the critical importance of this
document in determining whether the patient lives or
dies, the lack of verification and safeguards for protecting
life that this document represents should sound alarms.
Even the Dutch law emphasizes that the patient’s
request for assisted suicide must be insistent, lucid,
and preferably in writing.
Another alarm signal is that despite the lack of controls
when the document is being filled out, after
its completion the form becomes prominently visible.
In NC the form is printed on hot pink paper and, as
part of the physician's orders for medical treatment,
becomes the first page of the patient's medical
chart. It travels with the patient wherever he
goes. It goes on the refrigerator when the patient
is receiving home health care.
LifeTree expressed serious concerns about the form
at the Medical Society meeting and will continue to
oppose use of the form and to express its concern with
POST's stated objective of expressing by medical orders
a “covenant” relationship between a patient
and his physician simply does not ring true.
Since the form is currently being introduced in nursing
homes and assisted living facilities in North Carolina
there is little likelihood that the physician who signs
the form will have had a long term relationship with
It is clear at this point that the pilot programs
will continue and that the proponents of this form will
continue to encourage its spread.
LifeTree was told by someone at the meeting that the
NC POST program will pass into law at some point. We
were also told that they will not introduce a bill until
there is "consensus."
We will try to alert you as we become aware of new
information. We believe that the light of day
needs to shine on the proponents of this form. Please
tell others and advise your local legislators.
God bless you.
Elizabeth D. Wickham, Ph.D.
Background information about POST/POLST and the Respecting
The POST form traces directly to the POLST Paradigm
Initiative originally developed in Oregon. POLST was
featured in Issue 3 of the Center for Practical Bioethics
(formerly Midwest Bioethics Center) State Initiatives
newsletter featured on
our timeline and available directly from Practical
explanation of the POLST Paradigm Initiative is at
the OHSU web site.
Briefly, here are the key elements:
- immediately actionable signed medical orders on
a standardized form;
- orders that address whether or not to use a range
of life-sustaining interventions;
- a brightly colored, clearly identifiable form;
- portability across treatment settings.
According to a
state-by-state map the use of these programs based
on the POLST Paradigm are spreading rapidly.
There are endorsed programs in Oregon, Washington
and West Virginia and developing by implementation
of pilot programs in Wisconsin, Pennsylvania, New
York (MOLST form), Utah, Idaho, Michigan, Minnesota
(recent), New Mexico (recent), Nebraska, North Carolina,
Georgia, Tennessee, New Hampshire and Florida.
You can click on a particular state for contact information.
You may read about the Respecting
Choices Program in RWJF's Last Acts archives.
of the program specifically as it has been used
by The Carolinas Center is at the Innovations
in End of Life Care web site.
"When inevitable death is imminent in spite of the
means used, it is permitted in conscience to take the
decision to refuse forms of treatment that would only
secure a precarious and burdensome prolongation of life
as long as the normal care due to the sick person in
similar cases is not interrupted."Declaration on
Euthanasia, May 5, 1980
"The evaluation of probabilities, founded on waning
hopes for recovery when the vegetative state is prolonged
beyond a year, cannot ethically justify the cessation
of interruption of minimal care for the patient, including
nutrition and hydration. Death by starvation or dehydration
is, in fact, the only possible outcome as a result of
their withdrawal. In this sense it ends up becoming,
if done knowingly and willingly, true and proper euthanasia
by omission, "Address of John Paul II to the Participants
in the International Congress on "Life-Sustaining Treatments
and Vegetative State: Scientific Advances and Ethical
Dilemmas," Saturday, 20, March 2004