Approaching Death Improving Care at the End of Life (1997) / Chapter Skim
Currently Skimming:
7 Legal Issues
7 Legal Issues
Pages 188-206
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 188... ...
On the dramatic end of the continuum are the court cases about the legality of physician-assisted suicide, which were argued before the U.S. Supreme Court as this report was being drafted.
|
From page 189... ...
For example, how can prescription laws be modified so that they do not discourage effective pain management but still respond to legitimate concerns about misuse of controlled substances? For some issues, most notably assisted suicide and euthanasia, ethical concerns may dominate legal discussions, but practical issues also arise as described later in this chapter.
|
From page 190... ...
Other parts of this report document deficiencies in pain management and gaps in scientific knowledge. This section examines how effective pain management may be compromised by prescription drug laws that are intended to minimize drug addiction and diversion of drugs from legal to Regal sources.
|
From page 191... ...
The forms themselves are often difficult to obtain and, if incorrectly filled out, must be completed again by the physician. The triplicate forms also become available to the state medical board, which may choose to pursue disciplinary measures on the basis of such information.
|
From page 192... ...
. In addition to reducing regulatory barriers to effective pain prescribing practices, states could require that pain experts or palliative care specialists be represented on state medical boards to help inform board policies and interpretations.
|
From page 193... ...
Other agents such as beta-blockers, caffeine, and corticosteroids also produce physical dependence. Further, clinical evidence suggests that patients receiving opioids can be easily withdrawn from them in favor of an alternative, effective pain control mechanism if that is clinically indicated.
|
From page 194... ...
State medical boards may establish guidelines on pain-prescribing practices that constitute official statements of board policy. Such guidelines describe acceptable medical practice and notify health care practitioners of professional boundaries.
|
From page 195... ...
In 1974, the federal government, through the Federal Intractable Pain Regulation, clarified the federal law that prohibits physicians from prescribing opioids to detoxify or maintain an opioid addiction (Code of Federal Regulations, Title 21 Part 1300~. The regulation states that the prohibitive regulations are "not intended to impose any .
|
From page 196... ...
recognize the benefits of pain control and allow physicians to prescribe controlled substances but do not address concerns about inappropriate discipline by medical boards. The Texas and California acts do address this problem by prohibiting medical board discipline of physicians who follow the provisions within the laws.
|
From page 197... ...
An aciclitional problem arises when state laws clefine acicliction without regard to pain management. As noted earlier, California clefines aciclicts as "habitual users," which might inclucle patients taking opioicis for chronic pain.
|
From page 198... ...
INFORMED CONSENT AND ADVANCE CARE PLANNING A series of legal decisions over the past three decades has affirmed the right of people to refuse unwanted medical treatments (President's Commission, 1982; Faden et al., 1986; Appelbaum et al., 1987~. As stated in an important 1960 California Supreme Court case, "Anglo-American law starts with the premise of thoroughgoing self-determination," which includes the right of individuals to refuse medical treatments (Natanson v.
|
From page 199... ...
DNRs might, however, have some legal significance, if courts take them into account when determining whether a patient's preferences have been followed. Also, because the decision by the physician to place the DNR in the chart should be made in consultation with the patient and should reflect a patient's decision to forego certain forms of life-prolonging treatment, DNRs share with living wills and durable powers of attorney a role in the process of advance care planning.
|
From page 200... ...
Skeptics of living wills argue that these documents, which may be standard forms approved by the legislature of some states, provide little practical guidance in real life clinical situations, which often involve many more factors or contingencies than anticipated by standards forms (see, e.g., Brett, 1991; Lynn, 1991~. Indeed, by leading patients to believe that the signing of a living will means that their preferences for an end-of-life treatment plan have been made clear, these documents could even discourage active and ongoing discussions among patients, their families, and health care professionals.
|
From page 201... ...
This inflexible provision restricts people's ability to plan ahead and may prevent humane care at the end of life.8 Children Decisions regarding dying children involve special considerations (Lantos and Miles, 1989; Strain, 1994; AAP, 1995; Fleischman, 1996~. Although specific state laws vary, those below a certain age are legally unable to agree to or refuse medical treatment, and so others must make decisions for them.
|
From page 202... ...
. The PSDA requires health care institutions that receive Medicare or Medicaid funds to provide written information to adult patients about state laws regarding advance directives.
|
From page 203... ...
In this area of decisionmaking at the end of life, the law's favorite product the legally binding document may sometimes stand in the way of, rather than ease, the process, especially if these documents are naively viewed as ultimate solutions to the difficulties of decisionmaking. Rather, the documents known as advance directives should be seen as a set of tools useful in the ongoing process of advance care planning.
|
From page 204... ...
The committee agreed that it would not take a position on the legality or morality of assisted suicide, but it did examine some of the issues that might arise if the Supreme Court ultimately ruled either that a terminally ill person who is mentally competent and voluntarily chooses suicide has a constitutional right to self-administer lethal drugs received with the assistance of a physician or that it was constitutionally permissible for individual states, such as Oregon to permit the practice. Many of these issues were explored in friend-of-the-court briefs filed with the Court.l° Although proposals to legalize physician-assisted suicide typically include various safeguards or restrictions to protect patients and physicians, these provisions involve a number of ambiguities that might make them impossible or impractical to implement.
|
From page 205... ...
It also believes that the current serious deficiencies in the provision of care to dying peopledeficiencies highlighted throughout this report themselves compromise the autonomy principle by depriving individuals of many choices that should, and realistically can, be made available to them. As discussed in Chapter 5, substantial numbers of dying people today suffer from avoidable pain and other symptoms, and many of the arguments for physicianassisted suicide reflect fear of pain.
|
From page 206... ...
Legal documents have a role to play but should not deflect attention from the more significant and complex process of advance care planning as considered in Chapter 3. Deficiencies in care of the dying were recognized well before recent assisted suicide referenda, legislative activities, and court challenges.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.