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Legal and Ethical Concerns at the End of Life

By Elizabeth L. Cobbs, MD, Professor, Medicine, Geriatrics and Palliative Care;Chief, Geriatrics, Extended Care and Palliative Care, George Washington University;Washington DC Veterans Administration Medical Center ; Karen Blackstone, MD, Assistant Professor, Medicine, Geriatrics and Palliative Care;Director, Palliative Care, George Washington University;Washington DC Veterans Administration Medical Center ; Joanne Lynn, MD, MA, MS, Director, Center for Elder Care and Advanced Illness, Altarum Institute

  • Advance directives instruct family members and health care practitioners about a person’s decisions for medical care, if the person is unable to make such decisions when they are needed.

  • Some dying people consider suicide, although few people take any steps toward causing their own death.

  • In some areas, laws allow physician aid in dying if certain conditions are met and specific procedures are followed.

Advance directives

Health care advance directives are legal documents that communicate a person’s wishes about health care decisions in the event the person becomes incapable of making health care decisions. Advance directives should be in writing and comply with state law requirements. There are two basic kinds of advance directives: living wills and health care powers of attorney.

  • A living will expresses, in advance, a person’s instructions or preferences about future medical treatments, particularly end-of-life care, in the event the person loses capacity to make health care decisions.

  • A health care power of attorney appoints a person (called a health care agent or proxy, health care representative, or other name depending on the state) to make decisions for the person (the principal) in the event of incapacity (temporary or permanent) to make health care decisions.

Additionally, a growing number of state and local programs address a range of emergency life-sustaining treatments in addition to cardiopulmonary resuscitation (CPR—an emergency procedure that restores heart and lung function) for people with advanced illness. These programs are most commonly called Physician Orders for Life-Sustaining Treatment or POLST. POLST is applicable across all care settings. In a medical crisis, emergency medical technicians and other health care practitioners should first follow POLST.

POLST and similar programs involve a physician-initiated discussion and shared decision-making process with people with advanced or end-stage illness. It results in a portable set of medical orders written by the doctor, consistent with the person’s goals of care, addressing the person’s wishes in regards to the use of CPR, artificial nutrition and hydration, hospitalization, ventilation, intensive care, and other interventions that potentially could be used in a medical crisis.

However, even without written documents, a conversation between the patient, family, and health care practitioners about the best course of care gives substantial guidance for care decisions later, when the patient is unable to make such decisions, and is much better than not discussing the issues at all.

Suicide

Although very few people actually take any steps toward causing their own death, many dying people at least consider suicide—even more so as the public debate about doctor-assisted suicide grows. Discussing suicide with a doctor may help sort out the issues and often correct certain problems that prompted consideration of suicide. The doctor can increase efforts to control pain, depression, and other troubling symptoms. Other members of the care team, such as clergy members, can assure the person and family that they are cherished and help them find meaning. Nevertheless, some people opt for suicide to relieve an intolerable situation or to retain control of when and how they wish to die. Most people find that they have enough control by refusing treatments that might prolong life, including feeding tubes and ventilators. Making decisions to forgo life-sustaining treatment, forgo food and fluids when near death, or taking many drugs or large doses of drugs to relieve symptoms does not usually lead to death and is not considered suicide.

Physician aid in dying, sometimes referred to as assisted suicide, refers to the assistance given by doctors to people who wish to end their lives. It is very controversial because it reverses the usual goals of the doctor and the patient, which is to preserve life. Physician aid in dying is illegal in all states except Oregon, Washington, Montana, Vermont, Colorado, and California. In the rest of the United States, doctors can provide treatment intended to minimize physical and emotional suffering, but they cannot intentionally hasten death.