Legal Issues With Death and Dying

Whether as a doctor or as a patient, the focus on health is usually prolonging life. After all, a life cut short equals lost time that could have been more days to enjoy life. Medicine provides that miracle of life whenever disease strikes. Even so, people forget about the other side. What if one is debilitated with multiple medical conditions, especially if life is complete and there is nothing more to strive for? Prolonging life in this case would not be of much benefit.

As people think about the end of life, there are a wide variety of concerns to address. The information here will not cover everything. The prime focus are the legal issues related to preparation for death.

Advanced Directives

In the future, someone might be in a condition where he or she no longer has the capacity to make medical decisions, such as after a massive stroke or a prolonged cardiac arrest. It is therefore a good idea to be prepared as one grows older. There are two options for advanced directives, preparations made for medical decision-making before being unable to communicate one's wishes.

The living will is a legal document stating in detail what treatments one still wishes to have or not have at all. For example, it may say that he or she wants no heroic measures for resuscitation if the heart stops or breathing stops. Maybe a person does not want resuscitative measures for the heart, such as chest compressions and heart medications, but is fine with having a tube down the trachea and being on a ventilator for worsening breathing. Wishes regarding any other treatment, like feeding tubes, can be expressed as well. As long as the document is legal and in conjunction with the law, a loved one can have access to it and bring it to the attention of medical practitioners when needed.

In addition, one can select a trustworthy person to be a durable power of attorney for health care. Ideally, this is someone who is close to the patient and who knows him or her very well, usually a family member. The DPOA can communicate the patient's wishes to others and also be engaged in medical decision-making alongside the physician. This is someone who would do things only in the patient's best interest.

Do Not Resuscitate

Whenever a patient is admitted into the hospital, the physician asks what the patient would want done if the heart stops or breathing stops. At that time, either the patient or the DPOA, if applicable, can communicate the patient's wishes to the physician. If there are wishes for no resuscitative efforts in the event of a cardiac or pulmonary arrest, the physician will complete a Do-Not-Resuscitate order, including any details about specific treatments wanted or unwanted. Keep in mind that the patient still receives treatment for the disease that required hospitalization. A DNR order is not equal to "do not treat." All of this applies whether or not there are advanced directives.

Some people may want to be resuscitated for cardiac or pulmonary arrest but only if he or she will not end up becoming a "living vegetable." There is a problem with this request. One cannot simply predict whether a patient would be in a persistent vegetative state before actually performing heroic measures. The only way to know is to attempt resuscitation and see what happens. Anything can happen once resuscitation starts. Decisions about resuscitation or no resuscitation must take this into account. Basically, those saying yes to heroic measures must be willing to take chances with any possible events down the line.

Palliative Care

Now suppose the patient reaches a point where he or she is still alive but has a condition or set of conditions that have little chance for success even with aggressive treatment. This is a time when the patient and the family will likely have a difficult time coping. However, after some time to think things over, everyone may come to terms with the idea of death. When this happens, the goal of therapy changes from prolonging life to providing comfort.

Palliative care, also called comfort care, focuses on relief of pain, nausea, and other unpleasant symptoms in someone with incurable disease. If a patient is in the hospital and wishes to remain there, then the physician can write a set of comfort care orders. All current orders for monitoring and treatments would be cancelled. In place would be a set of orders that may include morphine for pain, medications for nausea and vomiting, and oxygen as needed. The idea is to discontinue all efforts to counteract the disease and instead let the disease takes its course, giving treatment only for discomfort. All of this can also be done as hospice where one has comfort care in a special facility designed for it or has it set up at home.

The patient's final moments may be uncomfortable, and in such cases, morphine is given to relieve distress. For some, It may look as if morphine is hastening the patient's death, but it is not. The disease process is what leads to the patient's death. The morphine makes the final moments as peaceful as possible.

Final Words

Death and dying are not always easy to think about, but there are ways to become prepared and open to the idea. This will ensure a peaceful end of life when the time comes.

References

• Merck Manual - Medicolegal Issues
• American College of Physicians - Home Care Guide for Advanced Cancer

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