POLST of Oregon moves to NC and other states

Elizabeth D. Wickham, Ph.D.
Executive Director, LifeTree, Inc.

March 12, 2006

Dear all,

Last week 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 (POLST) form.

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 medical treatment.

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 death.

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 (

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” ones.

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 views.

"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 Colby.

There was much discussion at the NC Medical Society meeting about who signs the form and which signature is mandatoryNEITHER 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 the process.

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 the patient. 

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 Choices Program:

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 Bioethics.

Another good explanation of the POLST Paradigm Initiative is at the OHSU web site.

Briefly, here are the key elements:

  1. immediately actionable signed medical orders on a standardized form;
  2. orders that address whether or not to use a range of life-sustaining interventions;
  3. a brightly colored, clearly identifiable form; and
  4. 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.

A description 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