EPECEPECEPECEPEC EPECEPECEPECEPEC Legal Issues Legal Issues Plenary 2 The Project to Educate Physicians on End-of-life Care Supported by the American Medical Association and the Robert Wood Johnson Foundation

Objectives l Describe legal consensus points l List common legal myths and potential pitfalls l Describe legal consensus points l List common legal myths and potential pitfalls

Law and ethics– United States l Federal vs State l Lawmakers legislatures, judges, executive agencies l Enforcement criminal, civil, administrative l Federal vs State l Lawmakers legislatures, judges, executive agencies l Enforcement criminal, civil, administrative

Resolving difficult cases l Law l Ethics committees / consultants l Law l Ethics committees / consultants

Ethics of informed consent... l Information-giving standards standard professional reasonable person specific patient l Information-giving standards standard professional reasonable person specific patient

Ethics of informed consent... l Elements of information nature of procedure risks, common or severe benefitsalternatives l Elements of information nature of procedure risks, common or severe benefitsalternatives

... Ethics of informed consent l Consent understandingvoluntary understandingvoluntary

Procedures of informed consent l Documentation l Process of deliberation l Shared decision making l Communication of news l Physicians have direct responsibility l Documentation l Process of deliberation l Shared decision making l Communication of news l Physicians have direct responsibility

Treatment limitation at the end of life l Right to refuse any intervention l All patients have rights, even incapacitated l Withholding / withdrawing not homicide or suicide orders to do so are valid l Courts need not be involved l Right to refuse any intervention l All patients have rights, even incapacitated l Withholding / withdrawing not homicide or suicide orders to do so are valid l Courts need not be involved

Determining incapacity l General incapacity l Specific incapacity Is there a decision? Is the information understood? Is the reasoning logical and with appreciation for consequences? Is the decision sensible? l Reassess for each decision l General incapacity l Specific incapacity Is there a decision? Is the information understood? Is the reasoning logical and with appreciation for consequences? Is the decision sensible? l Reassess for each decision

Decisions for the incapacitated l Best interests l Substituted judgment advance directives surrogacy laws l Best interests l Substituted judgment advance directives surrogacy laws

Terminology of advance directives... l Advance care planning process of discussion, documentation, implementation l Advance care planning process of discussion, documentation, implementation

Terminology of advance directives... l Advance directives instructional statement living will values history personal letter medical directive l Advance directives instructional statement living will values history personal letter medical directive

...Terminology of advance directives l Statutory physician immunity l Advisory patient wishes l Proxy designation health care proxy durable power-of-attorney for health care l Statutory physician immunity l Advisory patient wishes l Proxy designation health care proxy durable power-of-attorney for health care

Appropriate use of opioids in end-of-life care l Federal and state l Principle of double effect l Federal and state l Principle of double effect

Physician-assisted suicide l United States Supreme Court 1997 l States free to develop laws l United States Supreme Court 1997 l States free to develop laws

Futility l Futile for what goal l Objective determinations of benefit l Use ethics consultation / committees l Transfer of care l Futile for what goal l Objective determinations of benefit l Use ethics consultation / committees l Transfer of care

Legal counsel and risk l State-by-state variations l Hospital counsel represents the institution l State-by-state variations l Hospital counsel represents the institution

EPECEPECEPECEPEC EPECEPECEPECEPEC Legal Issues Summary Summary