1. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Osteopathic EPEC Osteopathic EPEC Education for Osteopathic Physicians on End-of-Life Care Based on The EPEC Project, created by the American Medical Association and supported by the Robert Wood Johnson Foundation. Adapted by the American Osteopathic Association for educational use. American Osteopathic Association AOA: Treating Our Family and Yours

2. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Plenary 2 Legal Issues

3. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Objectives l Describe legal consensus points l List common legal myths and potential pitfalls

4. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Law and ethics–United States l Federal vs. State l Lawmakers Legislatures, judges, executive agencies l Enforcement Criminal, civil, administrative

5. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Resolving difficult cases l Law l Ethics committees / consultants

6. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Ethics of informed consent... l Information-giving standards Standard professional Reasonable person Specific patient

7. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Ethics of informed consent... l Elements of information Nature of procedure Risks, common or severe Benefits Alternatives

8. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours... Ethics of informed consent l Consent Understanding Voluntary

9. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Procedures of informed consent l Documentation l Process of deliberation l Shared decision making l Communication of news l Physicians have direct responsibility

10. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours 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

11. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours 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

12. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Decisions for the incapacitated l Best interests l Substituted judgment Advance directives Surrogacy laws

13. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Terminology of advance directives... l Advance care planning Process of discussion, documentation, implementation

14. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Terminology of advance directives... l Advance directives instructional statement ­ living will ­ values history ­ personal letter ­ medical directive

15. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours...Terminology of advance directives l Statutory Physician immunity l Advisory Patient wishes Proxy designation Health care proxy Durable power-of-attorney for health care

16. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Appropriate use of opioids in end-of-life care l Federal and state l Principle of double effect

17. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Physician-assisted suicide United States Supreme Court 1997 States free to develop laws

18. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Futility l Futile for what goal l Objective determinations of benefit l Use ethics consultation / committees l Transfer of care

19. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Legal counsel and risk l State-by-state variations l Hospital counsel represents the institution

20. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Legal Issues Summary