ADVANCED DIRECTIVES in HEALTH CARE: KINDS of DIRECTIVES

We have considered in a general way the topic of advanced directives in health care. Let us now consider some of the particular kinds of directives that can be made, namely, (1) health care proxies, (2) living wills, and (3) the POLST paradigm.

Health Care Proxies

A health care proxy a legal document by which one person designates another person as an agent who is authorized to make health care decisions for her in the event that she becomes unable to make her own health care decisions. A health care proxy is typically part of any procedure for making advanced directives. A person's health care agent should be someone who can be trusted to understand that person’s wishes and to carry them out faithfully and prudently. An agent should be someone who not only understands that person’s stated wishes, but understands that person. When completing a health care proxy, a person might designate an agent whom one considers to already have sufficient knowledge of his convictions, values, and preferences. He might also choose to guide one's proxy by expressing his wishes orally and/or in writing.

The agent whom a person designates with a health care proxy is not that person’s slave. It is immoral to try to bind the will of another person in order to make that person an instrument for carrying out one's own will. A health care proxy is a good way to ensure that decisions about one's health care will be made by someone who understands your values and will respect your wishes. For a Catholic, this can be a way of ensuring that the Church's teaching informs that decision-making process. The designated agent, however, must be respected as a free and conscientious actor, not as a mere instrument of the person he represents.

Living Wills

A living will is a legal document designating the kinds of life sustaining treatments that a person would or would not like to receive in a situation in which she is unable to express her wishes. These advanced determinations are to direct proxy decision-makers and medical personnel so that they can act in accordance with the patient's wishes. There are various kinds of life sustaining treatments that one can either request of refuse by means of a living will. A form that is valid in the state of New York includes cardiac resuscitation, mechanical respiration, artificial nutrition and hydration, and antibiotics. It designates the incurable conditions in which these life sustaining treatments may be refused as including "(a) a terminal condition; (b) a permanently unconscious condition; or (c) a minimally conscious condition in which [the patient is] permanently unable to make decisions" (www.caringinfo.org/files/public/ad/New_York.pdf). 

A living will can include directives that are reasonable and helpful to health care agents and medical personnel. Declining cardiac resuscitation when a patient is permanently unconscious would be one such example. However, these directives can also be unreasonable and even unethical. Consider, for example, a directive to withhold basic antibiotics from a terminally ill patient whose death would be unnecessarily hastened by an untreated infection. Moreover, living will directives are necessarily general and open to differing interpretations. A single directive can be applied in ways that are morally good in some circumstances but not in others. For example, a directive to withhold artificial nutrition and hydration from a permanently unconscious patient could, from the perspective of the Catholic Church, be applied in moral or immoral ways depending on the circumstance. The general directive lacks the specificity of the Church’s teachings about how to distinguish between ordinary and extraordinary means of preserving life in such circumstances.

The POLST Paradigm

POLST stands for “physician orders for life sustaining treatment." Other acronyms (MOLST, MOST, POST) are used to designate the same thing. These orders must be signed by a physician and are now recognized as valid in most U.S. states. POLST is meant to complement other forms of advanced directives and are recommended only for those who suffer from life-threatening conditions. Its stated purpose is to prevent unnecessary interventions and hospitalizations by supplying actionable orders to first responders and emergency personnel.

The POLST paradigm suffers from the same defect that we found in living wills, namely, the allowance of unreasonable and immoral refusal of treatment. Moreover, POLST are not just directives, but orders. They do not allow medical professionals to make treatment decisions based on the present condition of the patient, but instead issue orders without regarding the concrete circumstance.