[Advance Directives - Not a Lot of Margin for Error - The Surgeon's View of a Complex Medical-Legal Topic]. / Patientenverfügungen - welchen Spielraum erlauben sie? - Chirurgische Sicht auf ein komplexes medizinjuristisches Thema.

Since September 1st, 2009, the most recent version of the German "Betreuungsrechtsänderungsgesetz" has been validated by the legislators. It precisely sets out how physicians and nursing staff have to deal with a written declaration of a patient's will. This new law focuses in a special way on advance directives, describes the precise rules for the authors of an advance directive and shows both its sphere of action and its limitations. This article aims to give an overview on the legal scope of advance directives, and to illustrate potential limitations and conflicts. Furthermore, it shows the commitments and rights of the medical team against the background of an existing advance directive.

Beyond competence: advance directives in dementia research.

Dementia is highly prevalent and incurable. The participation of dementia patients in clinical research is indispensable if we want to find an effective treatment for dementia. However, one of the primary challenges in dementia research is the patients' gradual loss of the capacity to consent. Patients with dementia are characterized by the fact that, at an earlier stage of their life, they were able to give their consent to participation in research. Therefore, the phase when patients are still competent to decide offers a valuable opportunity to authorize research, by using an advance research directive (ARD). Yet, the use of ARDs as an authorization for research participation remains controversial. In this paper we discuss the role of autonomous decision-making and the protection of incompetent research subjects. We will show why ARDs are a morally defensible basis for the inclusion of this population in biomedical research and that the use of ARDs is compatible with the protection of incompetent research subjects.

Advance directives, dementia, and withholding food and water by mouth.

People with dementia who are no longer competent have limited control over how their lives end. But an advance directive to withhold food and water by mouth could be used to ensure that one does not live for years in severe dementia. Such directives are arguably already legal.

Legal briefing: voluntarily stopping eating and drinking.

This issue's "Legal Briefing" column covers recent legal developments involving voluntarily stopping eating and drinking (VSED). Over the past decade, clinicians and bioethicists have increasingly recognized VSED as a medically and ethically appropriate means to hasten death. Most recently, in September 2013, the National Hospice and Palliative Care Organization (NHPCO) called on its 2,000 member hospices to develop policies and guidelines addressing VSED. And VSED is getting more attention not only in healthcare communities, but also in the general public. For example, VSED was recently highlighted on the front page of the New York Times and in other national and local media. Nevertheless, despite the growing interest in VSED, there remains little on-point legal authority and only sparse bioethics literature analyzing its legality.This article aims to fill this gap. Specifically, we focus on new legislative, regulatory, and judicial acts that clarify the permissibility of VSED. We categorize these legal developments into the following seven categories: 1. Definition of VSED. 2. Uncertainty Whether Oral Nutrition and Hydration Are Medical Treatment. 3. Uncertainty Regarding Providers' Obligations to Patients Who Choose VSED. 4. Judicial Guidance from Australia. 5. Judicial Guidance from the United Kingdom.

[Legal issues of physician-assisted euthanasia. Part III--Passive euthanasia, comparison of international legislation, conclusions for medical practice]. / Rechtsfragen zur arztlichen Sterbehilfe. Teil III--Passive Sterbehilfe, internationaler Rechtsvergleich, Fazit für die arztliche Praxis.

The generic term "passive euthanasia" includes different issues dealing with the omission, discontinuation or termination of life-sustaining or life-prolonging medical treatments. The debate around passive euthanasia focuses on the constitutional right of self-determination of every human being on the one hand and the constitutional mandate of the State to protect human life on the other. Issues of passive euthanasia always require a differentiated approach. Essentially, it comes down to the following: In Germany, the human right of self-determination includes the right to prohibit the performance of life-sustaining treatments, even if this leads to the death of the patient. A physician who does not take life-sustaining treatment measures because this is the free will expressed by the patient is not subject to prosecution. On the other hand, if the physician treats the patient against his will, this can be deemed a punishable act of bodily injury. The patient's will is decisive even if his concrete state of health does no longer allow him to freely express his will. In the Patient's Living Will Act of 2009, the German legislator clarified the juridical assessment of such constellations being of particular relevance in practice. A written living will of a person in which he requests to take or not to take certain medical treatment measures in case that he is no longer able to make the decision himself shall be binding for the people involved in the process of medical treatment. If there is no living will, the supposed will of the patient shall be relevant. In its judgment in the "Putz case", the German Federal Court of Justice ruled in 2010 that actions terminating a life-sustaining treatment that does not correspond to the patient's will must be limited to letting an already ongoing disease process run its course. In this context it is not important, however, whether treatment is discontinued by an active act or by omission. Under certain circumstances, the termination of life-sustaining measures can also be permitted if they are no longer medically indicated. Looking to other European countries and the USA it becomes evident that euthanasia is the subject of controversial discussion and interpretation not only in Germany.

What are the consequences of disregarding a "do not resuscitate directive" in the United States?

Does a valid cause of action exist against a health care provider who intentionally disregards a "do-not resuscitate order," prolonging a patient's life? Wrongful prolongation of life has not gained traction in the United States. Although the issue has garnered media attention and has raised awareness of advanced directives, physicians still may disregard a patient's last wishes for fear of legal reprisal or due to lack of communication. This article examines key cases and explains the differences between living wills, advanced directives and proxies. Claims have been advanced under theories of battery, Constitutional violations, breach of contract, infliction of emotional distress, and negligence, but no cause of action has allowed monetary damages. Courts maintain that it is not their place to judge an impaired life as being less valuable than no life. A state-by-state analysis of legislation concerning advanced directives follows along with a discussion of the Patient Self-Determination Act.

A call to improve practice concerning cultural sensitivity in advance directives: a review of the literature.

BACKGROUND: The Patient Self Determination Act of 1990 mandates healthcare providers (HCP) to speak with patients about end-of-life preferences and advance directives (AD). HCP work with patients of varying cultures, and standard ADs do not address cultural differences. In order to understand various cultural beliefs, cultural sensitivity is important especially when discussing advance care planning (ACP). AIMS: Individuals from differing ethnic backgrounds are likely to turn to their traditional norms of practice when ill or treatment choices must be made. An AD that addresses varying cultural values and beliefs was sought. METHODS: A comprehensive review of the literature was conducted. Articles selected for review included qualitative and quantitative studies. The evidence was evaluated and synthesized for information related to cultural sensitivity and ADs. FINDINGS: Three common themes emerged related to ACP discussions and culture. Healthcare provider awareness, communication, and education concerning cultural differences and ACP assisted in meeting the needs for end-of-life planning in the current era of increased globalization. Education for HCP on cultural differences and how to lead discussions promoted ACP. IMPLICATION FOR PRACTICE: ADs are an essential part of health care and promote patient-centered care. (HCP) should be able to recognize differing cultural values and beliefs in order to initiate conversations about end of life. Initiating conversations about ACP can be facilitated by using open-ended questions that respect the values and beliefs of various cultures.

[Chances and limitations of patients' advance decisions at the end of life]. / Möglichkeiten und Grenzen antizipierender Willenserklärungen am Lebensende.

Death by "natural" causes is not appreciated in Western industrialized countries because it may be regarded as an obstacle against performance and consumption. In addition, life-saving therapies for patients with an infaust prognosis are often rather expensive and therefore classified as "futile". Utilitarian measures for the individual's quality of life (QALY's), which are allegedly objective, veil the fact that they can only reflect the parameters that have been considered during their construction. Caused by fear of a life in the nursing home, which is partially intensified by the media, many ethicists and lawyers propagate anticipating models of retaining patients' autonomy at the end of life. Apart from general considerations published by the former National Ethics Council in 2005, the German Parliament in 2009 will have to discuss three different bills concerning patients' advance decisions to refuse medical treatment. The illusion of "autonomous dying" is not a convincing model for the end of life debate.

Understanding Pennsylvania living wills: the 5 Ws.

The working world of nurses is often filled with deep-running emotions and physical exhaustion as we care for our dying patients. We feel the need to step back and gain perspective when faced with a dying patient, or more appropriately, a dying person. We must also keep in mind the family of the dying who may have similar feelings. It is nearly impossible to be a nurse and not have to care for a dying patient; thus, we often find ourselves dealing with living wills. The living will is the more common of the two forms of an advance directive; the other is the durable power of attorney for healthcare. Since living wills are so common, and laws about them vary from state-to-state, it is important for the professional nurse in Pennsylvania to understand how living wills work in our state. This may best be approached by considering the 5 Ws related to living wills.

Advancing an advance directive debate.

A challenge has recently been levelled against the legal and/or moral legitimacy of some advance directives. It has been argued that in certain cases an advance directive carries no weight in a decision on whether to withhold treatment, since the individual in the debilitating state is not the same person as the person who created the advance directive. In the first section of this paper, I examine two formulations of the argument against the moral legitimacy of the advance directives under review. The second section reviews, and criticizes, an objection to such arguments. In the penultimate section, possible models supporting the viability of the advance directives are considered. The final section makes good on an obligation incurred by the title of the paper.

The POLST (Physician Orders for Life-Sustaining Treatment) paradigm to improve end-of-life care: potential state legal barriers to implementation.

The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm is designed to improve end-of-life care by converting patients' treatment preferences into medical orders that are transferable throughout the health care system. It was initially developed in Oregon, but is now implemented in multiple states with many others considering its use. An observational study was conducted in order to identify potential legal barriers to the implementation of a POLST Paradigm. Information was obtained from experts at state emergency medical services and long-term care organizations/agencies in combination with a review of relevant state law.