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Chapter 5
Chapter 5

Caring for Patients at the End of Life

Caring for patients at the end of life is a privilege that draws deeply on physicians’ commitment to alleviate suffering. Physicians must help patients identify what matters most to them when cure is no longer possible and to negotiate difficult decisions about what trade-off to accept between quality and quantity of life, what interventions to accept, and when to refuse efforts to sustain life.

Caring for patients at the end of life

Physicians have a responsibility to help patients define their goals for end of life care and to respect patients' preferences.
Opinion 5.1

Advance Care Planning

Although often thought of primarily for terminally ill patients or those with chronic medical conditions, advance care planning is valuable for everyone, in order to ensure that their own values, goals, and preferences will inform care decisions when they cannot speak for themselves. Physicians should routinely engage their patients in advance care planning but should be sensitive to each patient’s individual situation and preferences when broaching this topic.
Opinion 5.2

Advance Directives

Advance directives are tools that give patients of all ages and health status the opportunity to express their values, goals for care, and treatment preferences to guide future decisions about health care. Advance directives also allow patients to identify whom they want to make decisions on their behalf when they cannot do so themselves. However, an advance directive never takes precedence over the contemporaneous wishes of a patient who has decision-making capacity.
Opinion 5.3

Withholding or Withdrawing Life-Sustaining Treatment

A patient who has decision-making capacity appropriate to the decision at hand has the right to decline or halt any medical intervention even when that decision is expected to lead to his or her death, When a patient lacks appropriate capacity, the patient’s surrogate may halt or decline any intervention. There is no ethical difference between withholding and withdrawing treatment. When an intervention no longer helps to achieve the patient’s goals for care or desired quality of life, it is ethically appropriate for physicians to withdraw it.
Opinion 5.4

Orders Not to Attempt Resuscitation (DNAR)

Orders not to attempt resuscitation (DNAR orders) direct the health care team to withhold resuscitative measures in accord with a patient’s wishes. Physicians should address the potential need for resuscitation early in the patient’s course of care, while the patient has decision-making capacity, and should encourage the patient to include his or her chosen surrogate in the conversation.
Opinion 5.5

Medically Ineffective Interventions

Physicians are not required to offer or to provide interventions that, in their best medical judgment, cannot reasonably be expected to yield the intended clinical benefit or achieve agreed-on goals for care. Respecting patient autonomy does not mean that patients should receive specific interventions simply because they (or their surrogates) request them.
Opinion 5.6

Sedation to Unconsciousness in End-of-Life Care

When a terminally ill patient experiences severe pain or other distressing clinical symptoms that do not respond to aggressive, symptom-specific palliation, it can be appropriate to offer sedation to unconsciousness as an intervention of last resort.
Opinion 5.7

Physician-Assisted Suicide

Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks. Instead of engaging in assisted suicide, physicians must respond to the needs of patients at the end of life.
Opinion 5.8

Euthanasia

Euthanasia is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks. Euthanasia could readily be extended to incompetent patients and other vulnerable populations. Instead of engaging in euthanasia, physicians must respond to the needs of patients at the end of life.