Ethics and Legal Issues
Ethics and Legal Issues
Ethical practice rests on autonomy, beneficence, nonmaleficence, justice, veracity, and fidelity. Capable patients may refuse any treatment, including artificial nutrition and hydration; withdrawing and withholding life-sustaining treatment are generally ethically equivalent. Informed consent requires capacity, disclosure, understanding, voluntariness, and authorization. Assess decision-making capacity, not competence, which is a legal term, and use surrogate decision makers according to state hierarchy and the patient's known values. The double effect applies when a proportionate dose is intended to relieve suffering even if death may be hastened; it is not a justification for intentional killing. Palliative sedation is not euthanasia or physician-assisted death. Know mandatory reporting, HIPAA, guardianship, and state-specific rules for POLST, minors, and aid-in-dying.
Traps: equating opioids with euthanasia; thinking do not resuscitate means do not treat; believing a feeding tube can be withdrawn only with a court order; allowing a family member to demand nonbeneficial treatment over a capable patient's refusal; and confusing ethics consultation with legal advice.
Worked example/rule of thumb: an imminently dying patient with a valid POLST saying comfort-focused treatment develops pneumonia. Antibiotics are a treatment decision based on goals, not automatically required or forbidden. Convene the team, clarify the order, and document. Rule: capacity, consent, and goals first; when conflict persists, use ethics consultation and follow policy.