Ethical and Legal Aspects of Hospice and Palliative Medicine
Principles and capacity
Know autonomy, beneficence, nonmaleficence, and justice, and be able to say which principle a vignette hinges on. Decisional capacity requires four abilities: communicating a choice, understanding the information, appreciating the consequences, and reasoning about options. Capacity is a clinical judgment documented at the bedside; competence is a legal determination by a court. An adult with capacity may refuse any treatment, including life-sustaining therapy, but cannot compel a treatment the clinician judges non-beneficial.
Surrogates and standards
The hierarchy of surrogate decision-makers is set by state statute. Surrogates apply substituted judgment - what this patient would have chosen - and fall back on best interests only when wishes are unknown. Encourage surrogates to see their role as interpreting values, not deciding alone, which reduces their burden.
End-of-life distinctions
Withholding and withdrawing life-sustaining treatment are ethically equivalent; stopping a ventilator is not killing. The rule of double effect applies to opioid titration for pain or dyspnea: the intent is symptom relief, the means is proportionate, and death is foreseen but not intended. A DNR order means no resuscitation - it does not mean no antibiotics, fluids, or comfort care. Medical aid in dying is jurisdiction-specific, requires a capacitated, voluntary, repeatedly requesting adult, and no clinician is obligated to participate; the obligation is to disclose and transfer care.
Practical legal issues
Protect confidentiality, know mandated-reporting duties, and document conversations, surrogate identity, and capacity determinations. When conflict seems intractable, use an ethics consult, and consider the process-based approach to futility claims rather than unilateral unilateral decisions.
Rule of thumb: when an order feels ethically murky, ask what the intervention is intended to accomplish and whether it can plausibly achieve it.