Patient, family members, and clinicians should consider the following:

• They should plan for increasing disability.
• Obtaining payment for end-of-life care may be difficult.
• Emphasis should be on improving quality of end-of-life, not on hastening death.

Managing disability: Progressive disability often accompanies fatal illnesses. Patients may gradually become unable to tend to a house or an apartment, prepare food, handle financial matters, walk, or care for themselves. Most dying patients need help during their last weeks. Disability should be anticipated and appropriate preparations made (eg, choosing housing that is wheelchair-accessible and close to family caregivers). Services such as occupational or physical therapy and hospice care may help a patient remain at home, even when the disability progresses.

Financial concerns: Financial coverage for care of dying patients is problematic. Medicare regulations restrict payment for many aspects of supportive care. Not all patients qualify for hospice care, and physicians are often reluctant to certify the 6-mo prognosis required for hospice coverage. Sometimes the need for skilled nursing care can justify Medicare payment to a nursing home for short-term, complex medical and nursing needs for dying patients. One study has shown that ¹/₃ of families deplete most of their savings when caring for a dying relative. The clinical care team should know the financial effects of choices and discuss these issues with patients or family members. Some attorneys specialize in elder care and can help patients and their family members deal with these issues.

Legal and ethical concerns: Health care practitioners should know local laws and institutional policy governing living wills, durable powers of attorney, and procedures for forgoing resuscitation and hospitalization. This knowledge helps them ensure that the patient's wishes guide care, even when the patient can no longer make decisions (see Medicolegal Issues).

Many health care practitioners worry that medical treatments intended to relieve pain or other suffering can hasten death, but this effect is actually quite uncommon. With thoughtful and skillful medical care, accusations of assisted suicide or other wrongdoing are almost nonexistent. Even if dyspnea requires doses of opioids that may also hasten death, the resulting death is not considered wrongful.

However, actually assisting with suicide (eg, by directly providing a dying patient with lethal drugs and instructions for using them) could be grounds for prosecution in most states but is authorized under specific conditions in Oregon. Charges of homicide are plausible if the patient's interests are not carefully advocated, if the patient lacks capacity or is severely functionally impaired when decisions are made, if decisions and their rationales are not documented, or if the prosecutor's electoral base is expected to approve of such charges. Physicians who manage symptoms vigorously and forgo life-sustaining treatment need to document decision making carefully, provide care in a reputable setting, and discuss these issues willingly, honestly, and sensitively with patients, other practitioners, and the public. A physician should not provide an intervention that is conventionally considered a means of homicide (eg, lethal injection) even if the intention is to relieve suffering.

Last full review/revision November 2007 by Joanne Lynn, MD, MA, MS

Content last modified February 2012