In Response to Professor Thaddeus Pope's article "Dangerous Catholic Attack on the POLST?"


The American Journal of Bioethics

Publish date

Dear Sir or Madam:

I read with interest Professor Thaddeus Pope’s article “Dangerous Catholic Attack on the POLST?” The title of that article is insensitive inasmuch as the words “dangerous Catholic” imply a religious bias that I am sure was not intended. Beyond this Pope’s article warrants rebuttal because it overstates the evidence supporting the form and is misleading.

Professor Pope asserts that “a number of scientifically rigorous studies have demonstrated POLST’s material benefits.” This is an exaggeration. There are only two scientifically rigorous studies of the POLST and these are large NIH funded studies in which a POLST advocate was the principal investigator. They found that end of life care will usually be consistent with what is written on the POLST in nursing home and hospice settings if the instructions are to limit treatment. The hospice study also found that patients with a POLST do not receive less symptom management. So if a patient is absolutely positively sure he or she does not want resuscitation or ICU care under any circumstance, and resides in a nursing home or hospice, these studies suggest the POLST can provide a benefit. Beyond this there is no “scientifically rigorous” supporting data. There are only small studies with multiple confounders.

The professor also says that POLST is “an approach to end-of-life planning based on conversations between patients, loved ones, and medical professionals.” However,there is no evidence that clinicians actually take the necessary time to conduct meaningful end of life conversations with patients. Instead, the POLST naturally lends itself to a cursory “checklist” approach to end of life planning. We need studies on how the POLST is actually implemented before it can be claimed that completion of the form results from a quality end of life conversation.

Pope goes on to write that “the general guidance is that the POLST form is only for seriously ill patients for whom their physicians would not be surprised if they died in the next year. Admittedly, this sort of prognostication is imprecise.” Imprecise is an understatement. Research on the “would you be surprised test” has found that a whopping 70% of individuals screened by this test are alive after one year. See e.g. Moss, et. al. Utility of the “Surprise” Question to Identify Dialysis Patients with High Mortality Clin J Am Soc Nephrol 3: 1379–1384, 2008. Moreover we are now seeing POLST statutes in New Jersey and Nevada that recommend the POLST for individuals with five years of life expectancy regardless of health.

Finally, Pope says that POLST “is better than all the other end-of-life healthcare decisions instruments that have been tried before.” This conclusion is based upon the flawed assumption that you can compare studies of living wills — which generally show poor physician compliance — with the research on the POLST. However you cannot compare studies conducted in different settings, at different times, and on different issues. There is no head-to-head study of the POLST versus living wills.

Professor Pope is wrong to categorize the objections to the POLST from Catholic clergy and scholars as “dangerous.” Many of those objections have merit. The sooner POLST advocates deal with them the better.


Jason W. Manne, J.D., Dr.PH

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