Legal aspects in palliative and end of life care
- Ezekiel J Emanuel, MD, PhD
Ezekiel J Emanuel, MD, PhD
- Vice Provost for Global Initiatives
- University of Pennsylvania
Caring for patients at the end of life is a challenging task that requires not only the consideration of the patient as a whole but also an understanding of the family, social, legal, economic, and institutional circumstances that surround patient care. Unfortunately, there are many myths and misconceptions about what may or may not be ethical and legal in this setting .
In the United States, fear of litigation may prompt unnecessary interventions or hinder clinicians from acting completely ethically in patients with life-threatening illnesses. One study found that as many as 93 percent of clinicians in high-risk medical specialties (ie, emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology, and radiology) report practicing defensive medicine such that they did testing beyond what they clinically felt was necessary . Understanding the legal aspects of end of life care should give the practicing clinician the confidence and freedom to act ethically and reasonably. Some of the legal standards regarding end-of-life care in the United States vary by state, but there are specific legal precedents surrounding end-of-life care that generalize. When in doubt, clinicians should consider an ethics consultation, seek legal counsel, or seek assistance from risk management.
This topic review will discuss issues related to legal aspects of end-of-life care that are specific to the United States. These may not apply to outside of the United States although many of the principles are becoming more widely accepted. Ethical issues regarding end of life care, euthanasia and physician assisted suicide, ethics in the intensive care unit, and the effect of religion and spirituality on end of life care are discussed separately. (See "Euthanasia and physician-assisted death" and "Overview of spirituality in palliative care" and "Ethics in the intensive care unit: Informed consent".)
Throughout the history of medicine, a primary responsibility for clinicians has been the care of dying patients. Over centuries, clinicians have developed ethical norms regarding care of the dying including the withdrawal and withholding of life-sustaining treatments.
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- HISTORIC PERSPECTIVE
- THE RIGHT TO REFUSE MEDICAL INTERVENTIONS
- PHYSICIAN-ASSISTED DEATH AND ITS RELATIONSHIP TO WITHHOLDING TREATMENT
- MEDICAL INTERVENTIONS THAT CAN BE STOPPED
- DECISION-MAKING CAPACITY
- Assessing capacity
- SURROGATE DECISION MAKERS
- Family decisions in court
- Methods for making decisions
- - Ordinary and extraordinary care
- - Futile treatments
- - Substituted judgment
- - Best interests
- ADDRESSING DIFFICULT CASES IN END-OF-LIFE CARE
- ADVANCE DIRECTIVES
- EUTHANASIA AND PHYSICIAN ASSISTED DEATH
- COMMUNICATION AND DOCUMENTATION
- INTERNATIONAL PERSPECTIVES
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS