special subjects
The Dying Patient
Legal and Ethical Concerns
Health care practitioners should know local laws and institutional policy governing Living will , Many health care practitioners worry that medical treatments intended to relieve pain or other serious symptoms (eg, opioids for pain or dyspnea) might hasten death, but this effect is actually quite uncommon. With skillful medical care and drug titration, health care practitioners avoid the most worrisome adverse drug effects, such as respiratory depression caused by opioids. Death is not hastened by common treatments for common symptoms in advanced illness. Even if intractable pain or dyspnea requires high doses of opioids that may also hasten death, the resulting death is not considered wrongful because the drugs had been given to relieve symptoms and had been appropriately titrated and dosed. Physicians who manage symptoms vigorously and forego life-sustaining treatment need to discuss these issues openly and sensitively and document decision making carefully. A physician should usually not provide an intervention that is conventionally considered a means of homicide (eg, lethal injection) even if the intention is to relieve suffering. Assisting with suicide (eg, by directly providing a dying patient with lethal drugs and instructions for using them) is authorized under specific conditions in California, Colorado, the District of Columbia, Hawaii, Maine, Montana, New Jersey, New Mexico, Oregon, Vermont, and Washington but could be grounds for prosecution in all other parts of the US. Physician-assisted suicide is also authorized in some other countries, including the Netherlands and Switzerland. In places where physician-assisted suicide is legal, health care practitioners and patients must adhere to local legal requirements, including patient residency, age, decision-making capacity, terminal illness, prognosis, and the timing of the request for assistance. In all other states and most countries, legislation or common laws prohibit physician-assisted suicide or are unclear. In these locations, charges of homicide are plausible, especially if the patient's interests are not carefully advocated, if the patient lacks capacity or is severely functionally impaired when decisions are made, or if decisions and their rationales are not documented. 