Legal and Ethical Issues Legal and Ethical Issues Affecting End-of-life CareAffecting End-of-life Care

Advance DirectivesAdvance Directives

The IssuesThe Issues

The outcomes related to their The outcomes related to their care should be their own wishes.care should be their own wishes.

The decisions may involve the The decisions may involve the choice for:choice for: Organ and tissue donationsOrgan and tissue donations Advance directivesAdvance directives ResuscitationResuscitation

Advance DirectivesAdvance Directives

A general term used to describe the A general term used to describe the documents that give instructions documents that give instructions about future medical care and about future medical care and treatmentstreatments

Advance Directives include:Advance Directives include: Living WillLiving Will Do Not Resuscitate OrderDo Not Resuscitate Order Withholding or Withdrawing TreatmentsWithholding or Withdrawing Treatments

Living WillLiving Will Was the first advance directiveWas the first advance directive The lay term used frequently to describe The lay term used frequently to describe

any number of documents that give any number of documents that give instructions about future medical care and instructions about future medical care and treatments or the wish to be allowed to die treatments or the wish to be allowed to die without heroic or extraordinary measures without heroic or extraordinary measures should the patient be unable to should the patient be unable to communicate for selfcommunicate for self

Most states have replaced the idea of living Most states have replaced the idea of living wills with the wills with the natural death actsnatural death acts

These include:These include: Directive to physicians (DTP)Directive to physicians (DTP) Durable power of attorney for health care (DPAHC)Durable power of attorney for health care (DPAHC) Medical power of attorney (MPOA)Medical power of attorney (MPOA)

Directive to physiciansDirective to physicians

A written document specifying A written document specifying the patient’s wish to be the patient’s wish to be allowed to die without heroic allowed to die without heroic or extraordinary measuresor extraordinary measures

Durable power of attorney for Durable power of attorney for health carehealth care

A term used by some states to A term used by some states to describe a document used for describe a document used for listing the person or persons to listing the person or persons to make health care decision should make health care decision should a patient become unable to a patient become unable to make informed decisions for self.make informed decisions for self.

Medical power of attorneyMedical power of attorney

Same as durable power of Same as durable power of attorney for health (depends on attorney for health (depends on state)state)

Person appointed may be called Person appointed may be called a health care agent, surrogate, a health care agent, surrogate, attorney-in-fact, or proxyattorney-in-fact, or proxy

Do Not ResuscitateDo Not Resuscitate A written physician’s order instructing A written physician’s order instructing

health care providers not to attempt CPRhealth care providers not to attempt CPR Often requested by familyOften requested by family Must be signed my a physician to be validMust be signed my a physician to be valid Several types of CPR decisions can be Several types of CPR decisions can be

made, including:made, including: Full codeFull code Chemical codeChemical code DNR or “no code”DNR or “no code” Out-of-hospital DNROut-of-hospital DNR

Full codeFull code

Complete and total heroic measures, Complete and total heroic measures, which may include CPR, drugs, and which may include CPR, drugs, and mechanical ventilationmechanical ventilation

Chemical codeChemical code

The use of drugs for resuscitation The use of drugs for resuscitation without the use of CPRwithout the use of CPR

DNR or “no code”DNR or “no code” Allows the person to die with comfort measures Allows the person to die with comfort measures

only and without the interference of technologyonly and without the interference of technology Becoming known as Becoming known as allow natural deathallow natural death (AND) (AND)

or or comfort codecomfort code

Out-of-hospital DNROut-of-hospital DNR

For use by terminally ill patients who wish to For use by terminally ill patients who wish to have no heroic measures used to prolong life have no heroic measures used to prolong life after they leave an acute care facilityafter they leave an acute care facility

Withholding or withdrawing Withholding or withdrawing treatmentstreatments

What is to be done and what is not to be What is to be done and what is not to be done must be included in clear termsdone must be included in clear terms

Honoring the refusal of treatments that a Honoring the refusal of treatments that a patient does not desire, are patient does not desire, are disproportionately burdensome to the disproportionately burdensome to the patient, or will not benefit the patient can patient, or will not benefit the patient can be ethically and legally permissiblebe ethically and legally permissible

The decision to withhold artificial nutrition The decision to withhold artificial nutrition and hydration should be made by the and hydration should be made by the patient or surrogate with the health care patient or surrogate with the health care teamteam

The Nurse’s ResponsibilitiesThe Nurse’s Responsibilities

Be aware of legal issues and the wishes of Be aware of legal issues and the wishes of the patientthe patient

Nursing care of dying patients is holistic Nursing care of dying patients is holistic and encompasses all aspects of and encompasses all aspects of psychosocial (grieving process) and psychosocial (grieving process) and physical needs (physical changes that are physical needs (physical changes that are associated with dying) associated with dying)

Focus on patient and family: respect, Focus on patient and family: respect, dignity, and comfortdignity, and comfort

Recognize own needs when dealing with Recognize own needs when dealing with grief and dying.grief and dying.

The EndThe End

QuizQuiz

Question 1Question 1

Who makes Who makes the decisions the decisions regarding end regarding end of life care?of life care?

Question 2Question 2

Complete and total Complete and total heroic measures, heroic measures, which may include which may include CPR, drugs, and CPR, drugs, and mechanical ventilation mechanical ventilation is referred to as what?is referred to as what?

Question 3Question 3

What is the lay term used What is the lay term used frequently to describe any number frequently to describe any number of documents that give instructions of documents that give instructions about future medical care and about future medical care and treatments or the wish to be treatments or the wish to be allowed to die without heroic or allowed to die without heroic or extraordinary measures, should the extraordinary measures, should the patient be unable to communicate patient be unable to communicate for self?for self?

Question 4Question 4

What is another What is another name for DNR name for DNR or “no code”?or “no code”?

Question 5Question 5

What is the general What is the general term used to describe term used to describe the documents that the documents that give instructions give instructions about future medical about future medical care and treatments?care and treatments?

Question 6Question 6

Who should be Who should be aware of legal aware of legal issues and the issues and the wishes of the wishes of the patient?patient?

Question 7Question 7

What has What has replaced the idea replaced the idea of living wills in of living wills in most states?most states?

Question 8Question 8

Nursing care of dying Nursing care of dying patients is ________ and patients is ________ and encompasses all encompasses all aspects of psychosocial aspects of psychosocial and physical needs.and physical needs.

Question 9Question 9

What is a written What is a written document specifying document specifying the patient’s wish to be the patient’s wish to be allowed to die without allowed to die without heroic or extraordinary heroic or extraordinary measures?measures?

Question 10Question 10

What is a written What is a written physician’s order physician’s order instructing health instructing health care providers not care providers not to attempt CPR?to attempt CPR?