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Legal and Ethical Concerns at the End of Life

by Elizabeth L. Cobbs, MD, Karen Blackstone, MD; Joanne Lynn, MD, MA, MS

  • 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.

  • The Death with Dignity Act in Oregon allows terminally ill citizens of that state to end their lives through the voluntary self-administration of lethal drugs prescribed by a doctor for that purpose.

Advance directives

People can give written directions called advance directives (see Advance Directives) about the type of care they do and do not want to receive when dying. Advance directives are legal written agreements that will be honored in the future when people can no longer communicate their wishes. For example, advance directives can prohibit resuscitation (the act of trying to revive a person whose heart has stopped) or tube feeding, if this is the person’s wish. Advance directives may be in the form of a living will, which expresses the person’s preferences for medical care; a durable power of attorney, in which the ill person designates another person to make health care decisions; or both.

People whose death may occur soon should also have Physician Orders for Life-Sustaining Treatment (POLST—see Physician Orders for Life-Sustaining Treatment (POLST)) documents. These documents are written doctor's orders that reflect the person's preferences for medical care (particularly whether to receive care or not). The documents are kept in the person's medical record and in the home and are used to direct emergency medical personnel in following the dying person's preferences. For example, these documents may contain the doctor's orders as to whether people should receive cardiopulmonary resuscitation (CPR—see First-Aid Treatment and see Resuscitation), transportation to a hospital, or aggressive treatments (such as blood transfusions or chemotherapy) to relieve symptoms even if death is inevitable. In most states, less formal decisions made during advance care planning between a person, family, and doctor are also powerfully helpful in shaping care to suit the person’s preferences.

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 take many drugs or large doses of drugs to relieve symptoms is not considered suicide.

The Death With Dignity Act was passed in Oregon in 1997. This law has made it legal for doctors in Oregon to prescribe lethal combinations of drugs for competent terminally ill people (a phrase that has a specific legal definition) to take when they decide to die. This law includes several measures to prevent potential abuses:

  • A mandatory waiting period

  • Counseling

  • A second medical opinion

Since 1997, three additional states, Washington, Vermont, and Montana, have approved similar acts. Similar acts are being considered in other states.