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EEPPEECC
EEPPEECC
Legal Issues Legal IssuesPlenary 2Plenary 2Plenary 2Plenary 2
The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation
The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation
ObjectivesObjectives
Describe legal consensus pointsDescribe legal consensus points
List common legal myths and List common legal myths and potential pitfallspotential pitfalls
Describe legal consensus pointsDescribe legal consensus points
List common legal myths and List common legal myths and potential pitfallspotential pitfalls
Law and ethics– United StatesLaw and ethics– United States Federal vs StateFederal vs State
LawmakersLawmakers
legislatures, judges, executive agencieslegislatures, judges, executive agencies
EnforcementEnforcement
criminal, civil, administrativecriminal, civil, administrative
Federal vs StateFederal vs State
LawmakersLawmakers
legislatures, judges, executive agencieslegislatures, judges, executive agencies
EnforcementEnforcement
criminal, civil, administrativecriminal, civil, administrative
Resolving difficult casesResolving difficult cases
LawLaw
Ethics committees / consultantsEthics committees / consultants
LawLaw
Ethics committees / consultantsEthics committees / consultants
Ethics ofinformed consent . . .Ethics ofinformed consent . . . Information-giving standardsInformation-giving standards
standard professionalstandard professional
reasonable personreasonable person
specific patientspecific patient
Information-giving standardsInformation-giving standards
standard professionalstandard professional
reasonable personreasonable person
specific patientspecific patient
Ethics of informed consent . . .Ethics of informed consent . . . Elements of informationElements of information
nature of procedurenature of procedure
risks, common or severerisks, common or severe
benefitsbenefits
alternativesalternatives
Elements of informationElements of information
nature of procedurenature of procedure
risks, common or severerisks, common or severe
benefitsbenefits
alternativesalternatives
. . . Ethics of informed consent. . . Ethics of informed consent ConsentConsent
understandingunderstanding
voluntaryvoluntary
ConsentConsent
understandingunderstanding
voluntaryvoluntary
Procedures of informed consentProcedures of informed consent DocumentationDocumentation
Process of deliberationProcess of deliberation
Shared decision makingShared decision making
Communication of newsCommunication of news
Physicians have direct responsibilityPhysicians have direct responsibility
DocumentationDocumentation
Process of deliberationProcess of deliberation
Shared decision makingShared decision making
Communication of newsCommunication of news
Physicians have direct responsibilityPhysicians have direct responsibility
Treatment limitation at the end of lifeTreatment limitation at the end of life Right to refuse any interventionRight to refuse any intervention
All patients have rights, even All patients have rights, even incapacitatedincapacitated
Withholding / withdrawingWithholding / withdrawing
not homicide or suicidenot homicide or suicide
orders to do so are validorders to do so are valid
Courts need not be involvedCourts need not be involved
Right to refuse any interventionRight to refuse any intervention
All patients have rights, even All patients have rights, even incapacitatedincapacitated
Withholding / withdrawingWithholding / withdrawing
not homicide or suicidenot homicide or suicide
orders to do so are validorders to do so are valid
Courts need not be involvedCourts need not be involved
Determining incapacityDetermining incapacity General incapacityGeneral incapacity
Specific incapacitySpecific incapacity
Is there a decision?Is there a decision?
Is the information understood?Is the information understood?
Is the reasoning logical and with Is the reasoning logical and with appreciation for consequences?appreciation for consequences?
Is the decision sensible?Is the decision sensible?
Reassess for each decisionReassess for each decision
General incapacityGeneral incapacity
Specific incapacitySpecific incapacity
Is there a decision?Is there a decision?
Is the information understood?Is the information understood?
Is the reasoning logical and with Is the reasoning logical and with appreciation for consequences?appreciation for consequences?
Is the decision sensible?Is the decision sensible?
Reassess for each decisionReassess for each decision
Decisions for the incapacitatedDecisions for the incapacitated Best interestsBest interests
Substituted judgmentSubstituted judgment
advance directivesadvance directives
surrogacy lawssurrogacy laws
Best interestsBest interests
Substituted judgmentSubstituted judgment
advance directivesadvance directives
surrogacy lawssurrogacy laws
Terminology of advance directives . . .Terminology of advance directives . . . Advance care planningAdvance care planning
process of discussion, documentation, process of discussion, documentation, implementationimplementation
Advance care planningAdvance care planning
process of discussion, documentation, process of discussion, documentation, implementationimplementation
Terminology ofadvance directives . . .Terminology ofadvance directives . . . Advance directivesAdvance directives
instructional statementinstructional statement
living willliving will
values historyvalues history
personal letterpersonal letter
medical directivemedical directive
Advance directivesAdvance directives
instructional statementinstructional statement
living willliving will
values historyvalues history
personal letterpersonal letter
medical directivemedical directive
. . .Terminology ofadvance directives. . .Terminology ofadvance directives StatutoryStatutory
physician immunityphysician immunity
AdvisoryAdvisory
patient wishespatient wishes
Proxy designationProxy designation
health care proxyhealth care proxy
durable power-of-attorney for health durable power-of-attorney for health carecare
StatutoryStatutory
physician immunityphysician immunity
AdvisoryAdvisory
patient wishespatient wishes
Proxy designationProxy designation
health care proxyhealth care proxy
durable power-of-attorney for health durable power-of-attorney for health carecare
Appropriate use of opioids in end-of-life careAppropriate use of opioids in end-of-life care Federal and stateFederal and state
Principle of double effectPrinciple of double effect
Federal and stateFederal and state
Principle of double effectPrinciple of double effect
Physician-assisted suicidePhysician-assisted suicide United States Supreme Court 1997United States Supreme Court 1997
States free to develop lawsStates free to develop laws
United States Supreme Court 1997United States Supreme Court 1997
States free to develop lawsStates free to develop laws
FutilityFutility
Futile for what goalFutile for what goal
Objective determinations of benefitObjective determinations of benefit
Use ethics consultation / committeesUse ethics consultation / committees
Transfer of careTransfer of care
Futile for what goalFutile for what goal
Objective determinations of benefitObjective determinations of benefit
Use ethics consultation / committeesUse ethics consultation / committees
Transfer of careTransfer of care
Legal counsel and riskLegal counsel and risk
State-by-state variationsState-by-state variations
Hospital counsel represents the Hospital counsel represents the institutioninstitution
State-by-state variationsState-by-state variations
Hospital counsel represents the Hospital counsel represents the institutioninstitution