Some states have laws that limit the doses a doctor can prescribe to a patient at any given time. These laws require pain patients requiring frequent medications to repeatedly apply for and renew prescriptions. Not only does this bother both patients and doctors, but it can expose patients to potential interruptions in pain management if something interferes with timely requests and responses. These issues are of particular concern to patients who are not in a medical facility, but at home or in a care facility without a local doctor. Finally, the legal assertions of these laws about the importance of pain control per se do not correct practice patterns and do not improve physician training. However, laws could encourage patients to expect care for pain relief, including the use of commonly effective medications. Medical boards may consider disciplining physicians who do not use proven methods of pain control. Ethical approach to such decisions. All physicians should be able to describe an ethical approach to decisions regarding refusal or discontinuation of treatment, taking into account the law, official guidelines, the evidence base, and available resources. You need to know the patient, their abilities, beliefs and preferences, as well as their clinical status and perspectives. The physician must then clearly formulate the ethical question posed and ensure that his or her own point of view does not influence the way in which it is posed. In this way, the available options can be determined, including moral justifications and practical solutions (Table 2).
To put this into practice, communication and coordination skills are required. This approach is now applied to joint end-of-life decisions. The statutes contain several safeguards against abuse. Most understand the requirement that both witnesses to the signing of the document do not need to be related to the patient, nor involved in their treatment or financial support. In addition, conclusions that the patient meets the legal definition of a terminally ill patient and is incapable of making decisions must sometimes be made by at least two physicians. A mentally competent person always has the right to revoke their advance directive. Statuses vary depending on whether diet and hydration are considered “artificial maintenance of vital functions” treatments. Some laws explicitly exclude nutrition and hydration from treatment, which a patient may refuse, others give the signatory the opportunity to explicitly include them, while a third group remains silent on the subject (Strauss et al., 1990). Responses to the problem of drug abuse take various forms, including some of those already identified in the discussion of drug diversion.
Federal and state laws and regulations aim to control prescribing behavior by doctors, nurses, and pharmacists by criminalizing certain activities. In addition to legislators and courts, state medical associations set guidelines that, while not formally enforceable by law, can be equally powerful in their effect. These guidelines dictate the standards by which physicians can be professionally sanctioned. Laws and guidelines for medical committees are also closely linked, as legislators can legally limit the scope of a medical committee`s powers. Health care providers are required by law to act in accordance with the terms of a living will or, if this is not possible, to transfer the patient to a health care provider who will do so. The provider cannot draw any conclusions about a patient`s end-of-life care preferences in the absence of a living will. When a living will is presented to a provider, it must be part of the patient`s medical record. Providers are also required to immediately certify if a patient is terminally ill. Power of Attorney for Health Care The Power of Attorney for Health Care is a document that allows the client to appoint an authorized representative who makes health and personal care decisions on behalf of the client.
Decisions are made in accordance with the principal`s specific instructions as to what decisions the agent can make, when the agent can make those decisions, and how the agent can make those decisions. Health care decisions made by an officer are effective without court approval. While the impact of malpractice litigation on medical practice is a complex and controversial issue, it is only briefly addressed as the Committee did not consider it likely that the prospect of malpractice litigation would have a significant impact on end-of-life care. However, the Panel recognized that physicians may engage in defensive medicine (e.g., ordering additional tests, prescribing unnecessary medications, performing hopeless CPR) because they fear being sued for a poor outcome that applicants may try to attribute to the lack of a test or procedure. Similarly, decisions can sometimes be influenced by fear of being sued for not following a family`s wishes, even if those wishes contradict the physician`s clinical judgment and the patient`s wishes. The Committee found no evidence that physicians were concerned about the responsibility for failing to intervene to relieve pain or other symptoms. Providing quality care while keeping an eye on patients` wants and needs should always be a nurse`s top priority. However, this can sometimes seem unclear when it comes to an ethical issue, especially at the end of a person`s life. Here are some of the most common issues you may face during end-of-life care: The Patient Self-Determination Act (PA) aims to increase the communication skills of health care providers and patients. It gives patients the right to express their decisions for end-of-life treatment, but this stage of life can come with limitations. As a nurse, it is important to respect the patient`s autonomy while keeping an eye on the best treatment without affecting the patient`s decision.
Nurses should encourage patients and their partners to discuss end-of-life care and use living wills so that patients` wishes can be maintained when patients lose their ability to make decisions about their care. Although health care organizations are required to provide information, the PSDSA does not disclose the content of that information. Patients are often informed of their rights regarding living wills when they are admitted to a hospital or care facility. The information is provided on a piece of paper, one of many that cross the table during this usually stressful time. There are other challenges to implementing the PSDA. One study found problems with the accessibility of living wills already completed during subsequent hospital stays (Morrison et al., 1995). Another study found that of the patient records indicating the existence of a living will, only 57.5% actually contained a copy of the instruction (Yates & Glick, 1995). The study also found that only 32 percent of medical facilities covered by the law had conducted municipal education on living wills. The lack of involvement of physicians, especially family physicians, also contributes to patients tending to neglect the information offered. Bishop, 1996). Physician surveys – discussed below – suggest that anti-diversion and anti-addiction policies combined with social antipathy towards real or imagined addiction prevent effective, appropriate and legal pain prevention and treatment.
If more than one health representative is appointed and disagreements arise, these disagreements must be resolved within the group or by a majority within the group. The patient does not need to be of sound mind to thwart a decision by the representative to refuse or withdraw life-sustaining treatments, but they must be of sound mind to thwart medical decisions. The health care provider may require the proposed representative to provide a written statement setting out the facts and circumstances that justify the proposed representative`s authority to act in that capacity. Once appointed, the health representative is empowered to make all health care decisions and to exercise all rights and powers relating to the care, custody and treatment of the disabled person that he or she would have exercised had he or she been competent. The “continuing” power of attorney differs from the general power of attorney in that it does not expire if the authorized representative loses his or her decision-making authority. This is an integral part of health care decision-making, as it is precisely at the moment of a patient`s incompetence that the role of appointed lawyer begins. In any event, many of the measures proposed in this report would address the problems of undertreatment, overtreatment or abuse of dying patients in a way that reduces the risk of litigation, uncertainty and physician fears about prosecution. At the practitioner level, these steps include changing clinicians` attitudes, knowledge, and practices so that they communicate more effectively with patients and families, engage patients and families in a goal-setting and decision-making process that builds trust and minimizes misunderstandings, and properly assesses and manages pain and other symptoms. At the system level, they include strategies for measuring, monitoring and improving care that aim to identify and respond to the preferences, experiences and feelings of patients and families.
