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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

    Treatment Limitation at End of Life: Legal Consensus
    • Treatment limitation
      • In the past 2 decades, federal and state courts have decided a number of cases that have established a consensus of important legal principles in end-of-life care

      • Though these principles have not been unanimously adopted by all federal and state courts and legislatures, the consensus that has emerged has been broadly accepted with a distinct minority of exceptions
    • Patients may refuse unwanted treatment
      • Patients with decision-making capacity may refuse unwanted medical treatment, even if this may result in their death

      • Based on both the common-law respect for bodily integrity and the liberty interest articulated in the 14th Amendment to the Constitution

      • Cruzan case: Most important expression of this principle was enunciated by the United States Supreme Court

        • Key question was whether an individual has a constitutional right to refuse treatment

      • Other courts affirmed this principle

      • Applies even when patient does not have life-threatening illness
    • Surrogate decision-making
      • Patients who lack capacity to make decisions have the same rights as those who have capacity

      • However, different manner to exercise these rights

      • Authorized surrogate decision-makers may make decisions to limit treatment for patients who lack decision-making capacity using standards as discussed below
    • Withholding/withdrawing life-sustaining medical treatment
      • Not homicide or suicide

      • Courts have drawn a distinction between
        • Intentionally causing a patient’s death
        • Allowing a patient to die as a result of the withdrawal of life-sustaining treatment

      • Legal consensus that both withdrawing and withholding treatment, if not wanted by the patient or ineffective, can be justifiable

      • Orders to do so are valid

        • Courts have also upheld the validity of DNR (do-not-resuscitate) and other treatment limitation orders

        • No limitations on the type of treatment that may be withheld or withdrawn
          • Courts rejected distinctions between "ordinary" and "extraordinary" treatment

          • Thus, ventilator withdrawal that may result in death is permissible

          • Even parenteral nutrition and hydration may be withheld or withdrawn under the same conditions as any other form of medical treatment

          • Physicians should provide the patient (or parents if the patient is a child) with
            • Information about his or her situation
            • Description of choices about all treatments
            • Assistance with decision-making

          • Physicians should not automatically assume that ventilators, feeding tubes, or other life-prolonging treatments are required
    • Courts need not be involved
      • Principles are established in legal doctrine

      • Physicians should feel comfortable applying them

      • Few situations that cannot be resolved by physician in collaboration with patient and family

      • Only rarely does limitation of life-prolonging treatment at the end of life require court intervention
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