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Cited by 192Palliative Care and End-of-Life IssuesPalliative and Oncologic CareEthics and bioethics in healthcare

Seven Legal Barriers to End-of-Life Care<SUBTITLE>Myths, Realities, and Grains of Truth</SUBTITLE>

Meisel, Alan·2000·JAMA
DOI 10.1001/jama.284.19.2495
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Abstract

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 Unpublished sources were also identified by participants, as was anecdotal clinical experience.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. JAMA. 2000;284:2495-2501.

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  • As described by the Supreme Court, there are 2 key differences between withdrawal of unwanted therapies and assisted suicide: clinician intent and the cause of death.

    “However, as described by the Supreme Court, 39 there are 2 key differences between withdrawal of unwanted therapies and assisted suicide.First is clinician intent-withdrawing an unwanted therapy, versus hastening death 40,41 -and second is the cause of death.”

    From Managing with pacemakers and implantable cardioverter defibrillators (2013) · cites this paper as [40]

  • In assisted suicide or euthanasia, death is caused by the intervention provided, prescribed, or administered by the clinician; in contrast, when a patient dies after a treatment is refused or withdrawn, the cause of death is the underlying disease.

    “In assisted suicide or euthanasia, death is caused by the intervention provided, prescribed, or administered by the clinician.In contrast, when a patient dies after a treatment is refused or withdrawn, the cause of death is the underlying disease.”

    From Managing with pacemakers and implantable cardioverter defibrillators (2013) · cites this paper as [40]

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Authors
Meisel, A.
Affiliations
American College of Physicians (US)
Corresponding author
Meisel, Alan
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2000-11-15
Volume
284
Issue
19
Pages
2495
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.284.19.2495
OpenAlex
W2005378335
Cited by
192
References
47
Citations by year
2026: 2 · 2025: 3 · 2024: 1 · 2023: 3 · 2022: 3 · 2021: 5 · 2020: 5 · 2019: 6 · 2018: 4 · 2017: 2 · 2016: 2 · 2015: 5 · 2014: 3 · 2013: 6 · 2012: 9
FWCI
18.76
Type
journal article
Language
en
Open access
closed
Locations
  • JAMA (publishedVersion)
  • PubMed (publishedVersion)
  • DigitalGeorgetown (Georgetown University Library) (submittedVersion)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ethics and bioethics in healthcare
Keywords
end-of-life care, legal barriers, advance directives, withholding and withdrawing treatment, life-sustaining treatment, physician liability, criminal prosecution of physicians, physician-assisted death, physician-patient relationship, informed consent, surrogate decision-making, legal myths, dying patients, pain management, physician-patient communication
MeSH terms
Ethics, Medical, Euthanasia, Passive, Palliative Care, Terminal Care, United States, Advance Directives, Suicide, Assisted, Guidelines as Topic, Euthanasia, Active, Voluntary, Intention, Double Effect Principle, Supreme Court Decisions

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