Objective
The American College of Physicians-American Society of Internal Medicine
(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 analyze critically
the available evidence and guidelines, and to offer consensus recommendations
on how to improve care of the dying. Topic selection and content presentation
were carefully debated to maximize the project's focus 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 Ethics and Human
Rights Committee, College leadership, and the Center for Ethics and Professionalism
at the ACP-ASIM.
Evidence
A literature review including a MEDLINE search of articles from 1970-1998
and review of end-of-life care literature and organizational bibliographies
was conducted. Unpublished sources were also identified by participants, as
was anecdotal clinical experience.
Consensus Process
The draft statement was debated by panel members over a series of 3
to 4 meetings. For this statement, the initial draft and subsequent revised
drafts were discussed in 1998-1999. The statement then underwent external
peer review and revision before panel approval and the journal peer 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 themselves 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 capacity requires evidence
that this was the patient's actual wish; (2) withholding or withdrawing of
artificial fluids and nutrition from terminally ill or permanently unconscious
patients is illegal; (3) risk management personnel must be consulted before
life-sustaining medical treatment may be terminated; (4) advance directives
must comply with specific forms, are not transferable between states, and
govern all future treatment decisions; oral advance directives are unenforceable;
(5) if a physician prescribes or administers high doses of medication to relieve
pain or other discomfort in a terminally ill patient, resulting in death,
he/she will be criminally prosecuted; (6) when a terminally ill patient's
suffering is overwhelming despite palliative care, and he/she requests a hastened
death, there are no legally permissible options to ease suffering; and (7)
the 1997 Supreme Court decisions outlawed physician-assisted suicide. Many
legal barriers to end-of-life care are more mythical than real, but sometimes
there is a grain of truth. Physicians must know the law of the state in which
they practice.