Seven legal barriers to end-of-life care - Myths, realities, and grains oftruth

Objective The American College of Physicians-American Society of Internal M edicine (ACP-ASIM) End-of-Life Care Consensus Panel was convened in 1997 to identify clinical, ethical, and policy problems in end-of-life care, to an alyze critically the available evidence and guidelines, and to offer consen sus recommendations on how to improve care of the dying. Topic selection an d content presentation were carefully debated to maximize the project's foc us on providing practical clinical and other guidance to clinicians who are not specialists in palliative care. This statement examines current legal myths, realities, and grains of truth in end-of-life care. Participants The Consensus Panel comprises 13 medical and bioethics experts , clinicians, and educators in care at the end of life selected by the Ethi cs and Human Rights Committee, College leadership, and the Center for Ethic s and Professionalism at the ACP-ASIM. Evidence A literature review including a MEDLINE search of articles from 19 70-1998 and review of end-of-life care literature and organizational biblio graphies was conducted. Unpublished sources were also identified by partici pants, as was anecdotal clinical experience. Consensus Process The draft statement was debated by panel members over a s eries of 3 to 4 meetings. For this statement, the initial draft and subsequ ent revised drafts were discussed in 1998-1999. The statement then underwen t external peer review and revision before panel approval and the journal p eer review process. Conclusions Legal myths about end-of-life care can undermine good care and ethical medical practice. In addition, at times ethics, clinical judgment, and the law conflict, Patients (or families) and physicians can find themse lves considering clinical actions that are ethically appropriate, but raise legal concerns. The 7 major legal myths regarding end-of-life care are: (1 ) forgoing life-sustaining treatment for patients without decision-making c apacity requires evidence that this was the patient's actual wish; (2) with holding or withdrawing of artificial fluids and nutrition from terminally i ll or permanently unconscious patients is illegal; (3) risk management pers onnel must be consulted before life-sustaining medical treatment may be ter minated; (4) advance directives must comply with specific forms, are not tr ansferable between states, and govern all future treatment decisions; oral advance directives are unenforceable; (5) if a physician prescribes or admi nisters high doses of medication to relieve pain or other discomfort in a t erminally ill patient, resulting in death, he/she will be criminally prosec uted; (6) when a terminally ill patient's suffering is overwhelming despite palliative care, and he/she requests a hastened death, there are no legall y permissible options to ease suffering; and (7) the 1997 Supreme Court dec isions outlawed physician-assisted suicide. Many legal barriers to end-of-l ife care are more mythical than real, but sometimes there is a grain of tru th. Physicians must know the law of the state in which they practice.