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

EEPPEECC

EEPPEECC Legal Issues Legal Issues

SummarySummaryLegal Issues Legal Issues

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