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  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Legal Issues

    Informed Consent

    Informed Consent


    • First, many patients and families (or parents if the patient is a child) who are facing treatment withdrawal
      • May have not been fully informed of the risks and benefits of the therapy at the time it was begun
      • May not have been told that treatment would be withdrawn if the treatment was no longer effective
      • Knowing the burdens of continued treatment, the fully informed patient or surrogate may not elect further treatment
    • Second, patients and families who refuse further treatment should be told the consequences of the discontinuation of treatment, just as they are told the benefits and risks of other interventions



    • Information giving standards
      • Reasonable information-giving is judged partly by
        • What any good professional would give
        • What any reasonable person would want in the same circumstances
        • What this specific patient would want in these circumstances
          • Specific patient goals not legally required
          • Nonetheless, an important ethical goal
    • Elements of information
      • Nature of procedure
      • Risks, common or severe
      • Benefits
      • Alternatives
    • Consent: As important as information giving, or more so
      • Understanding
        • Must involve proper understanding
        • For example, does the patient understand that the consequence of declining life-prolonging intervention is probably an earlier death?

      • Voluntary and free of coercion



    • Documentation
      • Usually, health care facilities have a predrafted form that can be used

      • However, documentation is of no risk management benefit if the process was absent or ineffective
    • Process of deliberation and shared decision-making
      • Ideally woven into regular clinical interaction

      • Reflects a deliberative relationship in which the physician fosters and advocates for the well-being of the patient, the health care values, and the goals and specific wishes
    • Communication of news about the disease and its management
      • Timely
      • Sensitive
    • Physicians have direct responsibility for bringing the information into focus before settling on a specific decision together
      • Decisions are significantly determined by external constraints (e.g., insurance carriers, managed care organization’s coverage and reimbursement policies)

      • Nonetheless the direct responsibility for informed consent falls to physicians

      • Even with the recent trend of holding plans liable for patient care decisions, the physician remains most directly available to and responsible for patient and surrogate decisions
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