Have you ever cared for a terminally ill patient who has asked to die? Though you may feel uncomfortable dealing with such situations, it is imperative to have a plan for dealing with them.

Only two states—Oregon and Washington—have laws that provide governmentally regulated procedures for allowing a patient's assisted-suicide request to be honored.

If you practice in one of those states and want to participate in the program, the best way to protect yourself is by following the letter of the law. The procedures may seem onerous, but they are there for your protection, as well as the patient's. Request a psychiatric consult if you have any doubt about the patient's capacity or depression. Document everything, so you can prove that you followed protocol. The laws in Oregon and Washington offer immunity to physicians who demonstrate a good-faith effort to follow their provisions. (For more on "Death With Dignity" laws in Oregon and Washington.)

Of course, most doctors practice in states without an assisted-suicide law. In those states, you must simply tell the patient that you cannot comply with the request.

Virtually all states, however, have laws that can help physicians and patients in end-of-life decision-making. "Informed consent" means adults with capacity have the right to accept or refuse recommended treatment on their own behalf.

If terminally ill patients wish to forgo surgery, chemo, and radiation therapy, they have an absolute right to do so by signing a "refusal of consent" form. The very act of presenting such a form often helps focus the patient on the importance of what you're recommending. Nothing can guarantee that you won't be sued, but many plaintiffs' attorneys will not accept a case in which the patient has signed a refusal of consent. (For a sample refusal of consent form, go to http://www.memag.com/refusalform.)

Let's further suppose that the terminally ill patient is in pain and requests a morphine drip. Regardless of your state, you can prescribe medication to control the pain, but your informed-consent discussion should include information about what dosage the patient can safely take and what dosage would be considered lethal. If the patient stockpiles the medication and takes a lethal overdose, you will need to be able to defend your prescription procedures.

Most of these end-of-life decisions arise in a hospital environment, and most hospitals have an ethics committee. Whenever possible, refer such matters to the committee to get its opinion and possibly a consensus. It shows that you are taking all possible measures and establishes something of a standard of care, both of which provide some insulation from liability.

The author is a healthcare attorney in Mt. Kisco, New York, specializing in risk-management issues. She can be reached at lj@bestweb.net
. Malpractice Consult deals with questions on common professional liability issues. Unfortunately, we cannot offer specific legal advice. If you have a general question or a topic you'd like to see covered here, please send it to memalp@advanstar.com
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