A form directing physicians to withhold or continue lifesaving treatment for terminally ill patients is missing from statewide pilot program Honoring Choices Wisconsin, designed to educate more people about end of life care. The controversial Physician Orders for Life-Sustaining Treatment (POLST) is excluded because critics, including Catholic bishops, say the form lays a foundation for euthanasia and abuse, while proponents consider the POLST an advocate for terminal patients’ rights.

“POLST is a physician order that does not need the patient’s own writing,” explains Katharine Karage, Advance Directives Coordinator at Mayo Health System in La Crosse, Wisconsin. “POLST is four questions where the physician identifies with their patient what areas of care you want depending on what your illness is.”

POLSTs are more detailed than conventional living wills or advance directives. They allow patients to indicate preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes. Such forms are intended for patients in their last year of life, and they can follow patients across care settings and direct doctors to provide or withhold lifesaving treatment.

Tim Bartholow, chief medical officer of the Wisconsin Medical Society, chose not to include POLST as part of the statewide pilot. “POLST is the lightning rod at the moment,” he told the Journal Sentinel. ”I think we’ll get there, but it could be three or four years before there’s consensus about this.”

POLST aims to ensure patient wishes are executed in hospitals and unexpected medical situations. POLSTs were first developed in Oregon during the 1990s.

A sample POLST obtained by the Journal states: “Any section not completed indicates full treatment for that section. When need occurs, first follow these orders. Then contact physician.”

“Families were saying, ‘Why can’t we talk to each other?’ and ‘If we write orders in one place, why are they ignored in another?” says Margaret Murphy Carley, executive director of the National POLST Paradigm Task Force at the Oregon Health and Science University. ”So you have an advanced directive. Where is it? In a drawer? In a safety deposit box? That’s the problem.”

Stephen Pavela, an internist with the Mayo Clinic Health System-Franciscan Healthcare in La Crosse, opposes statewide implementation, though Mayo has used POLSTs since 1997. ”POLSTs lock into place orders that in the moment might not be appropriate and might be dangerous,” he told the Journal.

Wisconsin’s Roman Catholic Bishops issued a warning against the use of POLST. “A POLST form presents options for treatments as if they were morally neutral,” the bishops wrote in a letter published by the Wisconsin Catholic Conference. “In fact they are not.”

The letter continues: “A POLST oversimplifies these decisions and bears the real risk that an indication may be made on it to withhold a treatment that, in particular circumstances, might be an act of euthanasia.”

Bud Hammes, who leads the Respecting Choices program at Gundersen Lutheran Hospital, says that opponents aren’t understanding the many issues that arise in end of life care. “I work shoulder to shoulder with doctors and nurses who care every day for dying patients. They see the pain. They see the suffering when there is not good planning.” The Respecting Choices program will train participating health systems and organizations to properly use POLST.

“What makes this program tick is the redesigning of health systems so that it becomes part of routine care. We need to make sure it’s not an afterthought, and not something the patient does on their own,” Hammes says.

The Journal reports that fifteen states have endorsed POLSTs with legislation or administrative rules protecting providers who sign and follow them from legal liability. Some 20 others are developing POLST programs.

Read more about Honoring Choices Wisconsin here.

Read the bishops’ letter here.

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