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Právne aspekty neposkytnutia a prerušenia život udržujúcej liečby


 | 22.3.2011 | komentárov: 1397

Štúdie (ukazujú, že väčšina pacientov na jednotkách intenzívnej starostlivosti v USA zomiera počas výkonu paliatívnej liečby pri neposkytnutí či prerušení život udržujúcej liečby. Neposkytnutie a prerušenie život udržujúcej liečby sú postupy, pri ktorých sa rôzne medicínske zákroky pacientom buď neposkytnú alebo prerušia s očakávaním, že pacienti zomrú na chorobu, ktorou trpia. Paliatívna starostlivosť je prevenciou alebo liečbou bolesti, dýchavičnosti alebo iných prejavov utrpenia smrteľne chorých pacientov. Ak chcete vedieť viac, prečítajte si zaujímavý článok

Obrazok

Štúdie (1-3) ukazujú, že väčšina pacientov na jednotkách intenzívnej starostlivosti v USA zomiera počas výkonu paliatívnej liečby pri neposkytnutí či prerušení život udržujúcej liečby.
Neposkytnutie a prerušenie život udržujúcej liečby sú postupy, pri ktorých sa rôzne medicínske zákroky pacientom buď neposkytnú alebo prerušia s očakávaním, že pacienti zomrú na chorobu, ktorou trpia. Paliatívna starostlivosť je prevenciou alebo liečbou bolesti, dýchavičnosti alebo iných prejavov utrpenia smrteľne chorých pacientov.

Tieto úzko súvisiace postupy podporujú etické princípy autonómie, beneficiencie (prospešnosti) a neškodenia (nonmaleficence) tak ako o tom pojednávame v tomto (4) alebo iných súvisiacich článkoch (5). Avšak, aj keď lekári a iní zdravotnícki pracovníci poznajú tieto princípy, nemusia rozumieť zákonom, ktoré upravujú neposkytnutie a prerušenie život udržujúcej liečby a poskytovanie paliatívnej starostlivosti či tomu, ako splniť zákonné požiadavky vzťahujúce sa na ich prax. Tento článok bol napísaný s cieľom zlepšiť ich znalosti.

Právne aspekty neposkytnutia a prerušenie život udržujúcej liečby

V Spojených štátoch je neposkytnutie a prerušenie život udržujúcej liečby právne podložené princípmi informovaného súhlasu a informovaného odmietnutia. Obidva majú silné základy v common law. Podľa týchto princípov sa liečba nemôže začať bez súhlasu pacienta alebo jeho zástupcu okrem núdzových prípadov, pričom pacienti alebo ich zástupcovia môžu odmietnuť niektorý prípadne všetky liečebné postupy. Tieto princípy sa začali na starostlivosť o vážne chorých uplatňovať od prípadu Quilan(6). V ňom Najvyšší súd štátu New Jersey stanovil, že pacientka mala právo odmietnuť mechanické okysličovanie a vzhľadom na to, že bola vo vegetatívnom stave a nemohla toto svoje právo vykonať priamo, jej rodičia ju mohli zastúpiť Odvolací súd štátu Kalifornia zaujal rovnaké stanovisko k prípadu Barber (7), v ktorom  bolo vyhlásené, že lekári obvinení z vraždy nespáchali protiprávny akt, keď s dovolením pacientovej rodiny odstránili výživu a hydratáciu pacientovi v kóme.

Hoci princípy prezentované v prípadoch Quilan a Barber sú všeobecne prijímané, štatutárne právo a precedenty (case law) vzťahujúce sa na obmedzenia život udržujúcej liečby sa štát od štátu líšia. Otázka neposkytnutia a prerušenia život udržujúcej liečby bola prvýkrat zodpovedaná Najvyšším súdom v prípade Cruzan (8). Ten sa týkal žiadosti rodičov na odstránenie vyživovacej trubice ich nedospelej dcére, ktorá bola vo vegetatívnom stave. Cruzanovci žili v štáte Missouri, ktorý vyžaduje zvláštny dôkaz o tom, že pacient nespôsobilý na právne úkony by si želal, aby bola liečba prerušená. V tomto rozhodnutí súd umožnil Missouri a iným štátom požadovať jasný a presvedčivý dôkaz o želaniach pacientov, a tým v podstate obmedzil možnosti zástupcov pacientov rozhodovať za pacientov nespôsobilých na právne úkony v prípade, že chýba tzv. advance directive (predošlé prianie vyslovené pacientom). Každopádne, súd prijal princíp, že právo osoby oprávnenej na právne úkony vzdať sa starostlivosti vrátane vzdania sa výživy a hydratácie je slobodou chránenou 14. Dodatkom Ústavy.

Hoci najvyšší súd odobril neposkytnutie a prerušenie život udržujúcej liečby na základe zásady informovaného odmietnutia, v prípade Cruzan neriešil koncept zbytočnosti (futility). Napriek úsiliu Scheidermana a jeho kolegov(9) je veľmi ťažké kvantifikovať zbytočnosť. Tento pojem môže mať iný význam pre lekárov a iný pre pacientov a ich zástupcov. Lekári sa často pri odporúčaní odmietnuť život udržujúcu liečbu odkazujú na zbytočnosť (1,2). Ba čo viac, v odpovedi na  prieskum, ktorý uskutočnil Asch a jeho kolegovia(10), niektorí lekári priznali, že jednostranne neposkytli alebo prerušili život udržujúcu liečbu, ktorú považovali za zbytočnú bez informovania pacientov alebo ich zástupcov či napriek ich protestom.

História právnych sporov týkajúcich sa zbytočnej liečby je taká, že pokiaľ súdy riešili spor medzi rodinami, ktoré uprednostňovali liečbu a lekármi, ktorí boli proti nej, takmer jednotne nariaďovali pokračovanie v liečbe (11). Takisto sa zdá, že sudcovia neradi spôsobujú smrť pacienta jako napríklad v prípade Baby K (12). V ňom súd žiadali, aby vopred schválil rozhodnutie lekára neposkytnúť liečbu a ten to odmietol.
Sudcovia a poroty sa ale zdajú byť rovnako neochotné trestať lekárov, ktorí postupujú zodpovedne a v rámci profesijných štandardov (4) pri odmietnutí  poskytnúť liečbu, ktorú považujú za nehodiacu. V tomto ohľade,  jediné jasné právom stanovené pravidlo o zbytočnej či neprospešnej liečbe je tradičný test zanedbania starostlivosti, ktorý pomeriava rozhodnutie lekára o liečbe so štandardným postupom pri poskytovaní zdravotnej starostlivosti. Následne stanovuje, že každá starostlivosť nevyhovujúca štandardu spôsobuje pacientovi ujmu. Otázka zanedbania starostlivosti vyvstala v prípade Gilgunn (13), v ktorom porota štátu Massachusetts neuznala zodpovednosť nemocnice alebo lekárov, ktorí v nej slúžia, po tom, čo pacientke odstránili dýchací prístroj napriek námietkam jednej z jej dcér. Tento prípad určil trend pre prípady zbytočnej liečby, v ktorých podľa všetkého majú lekári lepšie právne výsledky, keď odmietnu poskytnúť neprospešnú liečbu a následne obhajujú svoje rozhodnutia ako konzistentné s profesijnými štandardmi než keď sa snažia získať predbežný súhlas s neposkytnutím liečby.

Napriek výsledku prípadu Gilgunn a trendu, ktorý priniesol, odporúčame, aby lekári nepristupovali k jednostrannému konaniu. Takéto konania môžu byť s istotou považované za eticky vhodné, pokiaľ podporujú profesijnú integritu, záväzok každého lekára určovať morálne prijateľný výkon povolania.
V každom prípade, autonómia ostáva prvým etickým princípom sledovaným pri vzdaní sa život udržujúcej liečby, hoci väčšina kriticky chorých  pacientov musí realizovať svoju autonómiu cez zástupcov, pretože rozhodnutie o zdravotnej starostlivosti nemôžu spraviť sami. Etika tu berie do úvahy právo, pretože informovaný súhlas a informované odmietnutie sú primárne právne princípy, ktoré podporujú túto prax. Jednostranné konanie je taktiež riskantné: nezhody  medzi rodinami a lekármi zvyšujú riziko podania žaloby. Predsa aj neúspešná žaloba predstavuje značnú záťaž. Napokon totiž  vyjednávanie takmer vždy vyrieši aj tie najzávažnejšie spory (1,2).

Právne aspekty poskytovania paliatívnej liečby

Po prípade Cruzan Najvyšší súd v prípadoch Glucksberg (14) a Vacco (15) potvrdil svoj súhlas so vzdaním sa život udržujúcej liečby a tiež poskytol návod ako postupovať pri poskytovaní paliatívnej liečby. Tieto dva posledné prípady sa zaoberali ústavnosťou zákonov, ktoré  v štátoch Washington a New York zakazovali lekárom asistovanú samovraždu. V prípade Glucksberg, súd potvrdil právo spôsobilých pacientov odmietnuť liečbu, tak ako to bolo stanovené v prípade Cruzan. Súd tiež rozhodol, že pri spáchaní samovraždy alebo prijatí lekárskej asistencie pri spáchaní samovraždy nejde o otázku slobody smrteľne chorých pacientov, jednak kvôli dlhej tradícii zákazu samovraždy v Spojených štátoch a jednak kvôli legitímnym dôvodom štátu pretrvávať v názore, že asistovaná samovražda je ilegálna. V prípade Vacco, súd stanovil ďalšie rozdiely medzi asistovanou samovraždou a neposkytnutím a prerušením život udržujúcej liečby. Súd uvádza: „Každý, bez ohľadu na fyzický stav,  je oprávnený, pokiaľ je spôsobilý, odmietnuť život zachraňujúcu zdravotnú starostlivosť (life saving medical treatment). Nikto nesmie asistovať pri samovražde (...) Keď pacient odmietne život udržujúcu lekárskú strarostlivosť, tak zomrie na smrteľnú chorobu alebo patologické ochorenie, ale ak požije smrteľné lieky predpísané lekárom, sú tieto lieky tým, čo ho zabije.“

V prípadoch Glucksberg a Vacco, päť sudcov Najvyššieho súdu zdôvodňovalo vo svojich súhlasných stanoviskách k rozsudku názor, že štáty Washington a New York môžu zakázať asistovanú samovraždu, pretože v týchto štátoch nejestvujú žiadne právne prekážky, ktoré by bránili pacientom obdržať lieky na tíšenie bolesti a utrpenia, čím tu chýba dôvod na  asistovanú samovraždu. Ako uviedol sudca Breyer vo svojom súhlasnom názore k rozsudku v dvoch prípadoch: „Tam, kde by právo štátu bránilo poskytovaniu paliatívnej starostlivosti vrátane podávania liekov, ktoré sú potrebné pre zabránenie bolesti ku koncu života,  zakročenie proti takémuto zákonu by mal požadovať Najvyšší súd.“  Na základe týchto a iných vyjadrení, väčšina sudcov Najvyššieho súdu potvrdila, že ústavná záruka slobody jednotlivca zahŕňa slobodu prijať primerané prostriedky na uľavenie bolesti počas umierania (16). Burt (17) interpretoval tieto zvlásť poskytnuté názory sudcov ako indikujúce ochotu zo strany väčšiny sudcov nariaďovať prístup pacientov k paliatívnej liečbe.

Najvyšší súd odlíšil asistovanú samovraždu od paliatívnej liečby v prípadoch Glucksberg
a Vacco prijatím princípu dvojakého účinku. Ako vysvetľuje Quill a kol.(18), toto pravidlo rozlišuje medzi zamýšľanými a nepredvídanými účinkami prípadne následkami. Podľa tohto pravidla, konania ako podanie sedatív alebo analgetík, ktoré sledujú morálne správne účinky ako napríklad utíšenie bolesti, sú prípustné dokonca aj vtedy, ak spôsobia účinky z morálneho hľadiska zlé ako napr. urýchlenie smrti s tým, že bol zamýšľaný iba dobrý účinok. Zlý účinok
mohol byť predpokladaný, ale nesmel byť zamýšľaný. Zlý účinok nesmie byť prostriedkom k dobrému účinku a dobrý účinok musí prevážiť nad zlým, to znamená riskovanie smrti je v starostlivosti o smrteľne chorého človeka odôvodnené iba vtedy, ak nejestvujú menej riskantné spôsoby uľavenia jeho trápenia.

Súhlas súdu s paliatívnou liečbou zahŕňa sankcionovanie praktiky tzv. posledného podania sedatív, pri ktorej sú pacienti uvedení do kómy a následne im môže byť zastavená hydratácia a výživa. Pojem „posledné podanie sedatív“ sa objavil iba v poznámke v práci Quill a kol. Sudca O΄Connor sa však vyjadril v prospech tíšenia bolesti až do bodu bezvedomia, kým sudca Breyer zaznamenáva “potrebu podania sedatív, ktoré môžu skončiť kómou.“ Orentlicher (19) prirovnal posledné podanie sedatív k eutanázii, pretože zastavenie prísunu jedla a vody „nijak neslúži k utíšeniu trápenia pacienta, ale len k tomu, aby spôsobilo pacientovu smrť.“ Každopádne, podľa Quilla štáty môžu povoliť tzv. posledné podanie sedatív, ak „sa zakladá na informovanom súhlase a princípe dvojitého účinku. Presne tak ako štát môže zakázať asistovanú samovraždu a zároveň umožniť pacientom odmietnuť nechcenú liečbu na záchranu života, môže, pokiaľ ide o toto odmietnutie,  povoliť paliatívnu starostlivosť. Tá môže mať predpokladaný, ale nezamýšľaný dvojitý účinok v urýchlení pacientovej smrti.“

Quill (18) a kol. argumentovali, že posledné podanie sedatív nie je v súlade s pravidlom dvojitého účinku, pretože „život predlžujúca starostlivosť je zastavená s úmyslom urýchliť smrť.“ Posledné podanie sedatív môže byť kompatibilné s pravidlom dvojitého účinku, ak majú lekári v úmysle len utíšiť bolesť a utrpenie, a konať v súlade s pacientovým informovaným odmietnutím predpokladajúc, že pacienti alebo ich zástupcovia považujú
vyživovanie a hydratáciu za nechcenú liečbu. Avšak lekári, pacienti či ich zástupcovia si za týchto okolností môžu rovnako želať urýchlenie smrti, a Quill a jeho kolegovia majú preto pravdu v tom, že ľudský úmysel je komplexný. Táto komplexnosť bola preukázaná v štúdii o podávaní sedatív a analgetík počas neposkytnutia a prerušenia život udržujúcej liečby vypracovanej Wilsonom a kol (20), v ktorej lekári uviedli, že v 39 percentách kriticky chorých pacientov nariadili podanie liekov na urýchlenie smrti, hoci primárne sledovali zníženie bolesti, úzkosti a dýchavičnosti. Podobne, vo výskume vypracovanom Aschom(21), 16 percent zo sestier starajúcich sa o kriticky chorých pacientov uviedlo, že bolo účastných na asistovanej samovražde alebo eutanázii, často bez vedomia lekára.

Tak ako niektorí lekári a zdravotné sestry majú pomýlené motívy pri starostlivosti o zomierajúcich pacientov, to isté robia niektorí rodinní príslušníci, ktorí si želajú súčasne uľaviť bolesť aj urýchliť smrť, keď ich milovaní trpia. To, že takáto motivácia je rozšírená môže pravdepodobne zato,  že len málo lekárov podozrivých z účasti na asistovanej samovražde alebo eutanázií bolo aj potrestaných. Alpers (22) nedávno preskúmal databázy prípadov od rozhodnutia v prípade Cruzan z roku 1990, aby identifikoval zdravotníckych pracovníkov, ktorí údajne podali pacientom smrteľné dávky liekov a ktorých prípady boli preberané v médiách, boli obžalovaní alebo súdení. Zistil, že vyšetrovali najmenej 13 lekárov (vyjme Dr. Jacka Kervorkiana), ale žiadneho formálne neobžalovali ani nestíhali. Štyria lekári boli súdení za vraždu spojenú so starostlivosťou o zomierajúcich pacientov a dvaja ďalší boli boli obvinení z vraždy, jeden bol oslobodený, ďalší rozsudok bol zrušený v odvolacom konaní, jeden bol odsúdený a o jeho odvolaní sa koná a u ďalšieho sa súdne konanie
skončilo porotou neschopnou vyniesť verdikt. V rovnakom čase, boli vyšetrované dve zdravotné sestry, jeden súdny proces práve prebieha. Všeobecne sú prípady asistovanej
samovraždy alebo eutanázie ťažko úspešne stíhateľné, ak vierohodný znalecký posudok
podporí konanie lekára alebo ak pacient a jeho rodina súhlasili s  paliatívnou liečbou.

Aj keď súd v prípadoch Glucksberg a Vacco neuznal ústavné právo na lekárom asistovanú samovraždu, napriek tomu umožnil štátom legalizovať túto možnosť. V súčasnosti štát Oregon dovoľuje lekárom predpísať dávky kontrolovanej látky smrteľne chorým pacientom. Skúsenosť z tohto štátu nasvedčuje tomu, že lekárom asistovaná samovražda nie je rozšírená a táto prax sa nevyskytuje na jednotkách intenzívnej starostlivosti. Pacienti najčastejšie
žiadajú predpísanie potenciálne smrteľných liekov nie z dôvodu neznesiteľných bolestí (23), ale preto že sa obávajú straty samostatnosti. Kongres predložil legislatívny návrh nazvaný Pain Relief  Promotion Act of 1999, ktorý „má novelizovať Controlled Substances Act  s cieľom zlepšiť liečbu bolesti a paliatívnu starostlivosti bez toho, aby sa povolila asistovaná samovražda a eutanázia; či za inými účelmi“ (24). Ako uvádza Angell (25) ustanovenie umožňuje lekárom podať sedatíva a analgetiká zomierajúcim pacientom, dokonca aj ak to zvyšuje riziko úmrtia, ale „zakazuje úmyselné dávkovanie, distribúciu alebo poskytovanie kontrolovaných látok, za účelom spôsobenia smrti alebo asistovať inej osobe pri pokuse o smrť.“ V súlade s prípadmi Glucksberg a Vacco návrh zákona posudzuje správnosť konania
lekárov, nie na základe následkov, ale na základe povahy lekárových zámerov.

Splnenie zákonných požiadaviek

Budúcnosť PRPA ostáva pre tento text  nejasná. Aj keď prejde Kongresom a prezident
ho podpíše, návrh bude pravdepodobne čeliť spochybneniu zo strany štátu Oregon, keďže koliduje so štátom garantovanými právami. Bez ohľadu na budúcnosť zákona, lekári ktorí sa starajú o kriticky chorých pacientov by mali oceniť, že ich nálady zdieľajú  mnohí zákonodarcovia a že návrh zákona podporila Americká zdravotnícka asociácia (American Medical Association). Ak vezmeme do úvahy túto podporu a pozíciu Najvyššieho súdu, ako majú lekári a iní odborníci správne neposkytnúť a prerušiť život udržujúcu liečbu kriticky chorým pacientom a poskytnúť im paliatívnu starostlivosť? Inými slovami, aké konanie lekárov preukazuje úmysel uľaviť trápenie, ale nie urýchliť smrť?

Po prvé, zastavenie život udržujúcej liečby je právne odôvodnené, iba ak je život udržujúca liečba predstavuje neželanou starostlivosťou. Liečba by sa nemala poskytnúť a prerušiť iba so súhlasom pacientov alebo ich zástupcov, za predpokladu, že zástupcov majú. Lekári môžu založiť svoje odporúčania na obmedzenie starostlivosti na koncepte zbytočnosti, ale nemali by sa naňho odvolávať, aby odstránili život podporujúcu liečbu bez pacientovho alebo zástupcovho vedomia alebo proti ich námietkam.
Okrem toho, aj keď lekári vykonávajú prax v nemocniciach, ktoré majú svoje zásady pre uplatnenie konceptu zbytočnosti, mali by si uvedomiť, že tieto zásady primárne slúžia ako prostriedky pre posilnenie spoločného rozhodovania zdravotníckych pracovníkov a pacientov a ich zástupcov, nie ako nástroje na presadzovanie jednostranných rozhodnutí lekárov (26). Nakoniec, lekári môžu prerušiť život udržujúcu liečbu za pacientov, ktorí nemôžu prijať rozhodnutie a nemajú zástupcov, ale mali by zakladať svoje konanie rovnako ako zástupcovia v pravom slova zmysle na svojom najlepšom vedomí toho, čo by si želali samotní pacienti. Bez takéhoto vedomia,  lekári môžu jednať podľa toho, čo veria, že je v najlepšom záujme pacienta.

Po druhé, keďže neposkytnutie a prerušenie život udržujúcej liečby a poskytovanie paliatívnej starostlivosti zahŕňa okrem ošetrujúceho lekára aj iných lekárov, všetky zúčastnené strany by mali participovať na plánovaní ako bude liečba prebiehať. Alpersov vyššie citovaný prieskum trestných konaní ukazuje, že nezhoda medzi osobami poskytujúcimi starostlivosť o účele liečby, môže zvýšiť riziko uznania ich zodpovednosti. Všetci dotknutí lekári by mali súhlasiť, že budú poskytovať pacientovi maximálny komfort s minimom invazívnych zákrokov. Následne by mal byť oslovený  pacient a jeho rodina za účelom ich vyjadrenia prípadne schválenia postupu.

Po tretie, keďže cieľom paliatívnej liečby je poskytnúť komfort, opatrenia, ktoré nezbavujú bolesti, len urýchľujú smrť,  by mali byť vylúčené. Hoci väčšina pacientov zomrie do 24 hodín od neposkytnutia či prerušenia  život udržujúcej liečby, zomieranie môže trvať aj niekoľko dní (20, 27). Akokoľvek dlho to trvá, prijaté paliatívne opatrenia a ich tempo by mali byť diktované objektívnymi prejavmi pacientovho utrpenia, kedykoľvek to je možné. Lekári by mali nariaďovať podanie sedatív a analgetík pacientom, ktorí z nich majú prospech, ale nie v dávkach, ktoré môžu viesť k smrti. Jednotlivé dávky liekov by sa mali upravovať, či už nahor alebo nadol podľa fyziologických prejavov bolesti či nepohodlia ako hypertenzia alebo zmeny výrazu spôsobené bolesťou , najlepšie v súlade s písomnými protokolmi.
Truog a kolegovia(28) pripomenuli, že nervovo-muskulárne blokátory, ktoré môžu brániť spontánnemu dýchaniu by sa nemali podať po zastavení ventilátora, a ak už pacienti tieto lieky požili, ich nervovosvalová funkcia by mala byť obnovená, pokiaľ sa nepredpokladá, že smrť nastane rýchlo po tom, čo bol ventilátor odstránený alebo čakanie na pominutie účinkov nervovo-muskulárneho blokátora by prinieslo záťaž pre pacienta.
Rovnako injekcie chloridu draselného nemajú mať miesto počas neposkytnutia alebo prerušenia život udržujúcej liečby, pretože neprispievajú ku komfortu pacienta, ale len naznačujú úmysel urýchliť smrť

Napokon, keďže úmysel možno vyjadriť tak slovami  ako skutkami, účel paliatívnej starostlivosti a prostriedky k jeho dosiahnutiu by mali byť zaznačené v záznamoch.
V ich poznámkach by mali lekári dokumentovať, ako sa prijímali rozhodnutia ohľadom odopretia život udržujúcej liečby a ako prebiehalo zabezpečenie komfortu pacienta.
Pokyny pre podávanie sedatív a analgetík by mali byť napísané tak, aby obsahovali presné obmedzenie dávkovania, ale ponechávalo nejakú voľnosť pre ošetrujúci personál, tak aby mohol byť zabezpečený komfort pacienta. V svojich poznámkach by mali zdravotné sestry uviesť, ako sa rozhodlo o účele paliatívnej starostlivosti a aké kroky podnikli, aby ho dosiahli vrátane uvedenia všetkých sedatív a analgetík, ktoré podali. Záznamy o účele paliatívnej starostlivosti zapoja etickú či dokonca zákonnú povinnosť lekárov a zdravotných sestrier zmierniť utrpenie do hociakého pokusu retrospektívne zhodnotiť poskytnutú starostlivosť, ktorý by sa mohol vyskytnúť v trestnom alebo občianskoprávnom konaní.

Zdrojový text: JOHN M. LUCE and ANN ALPERS. Legal Aspects of Withholding and Withdrawing Life Support from Critically Ill Patients in the United States and Providing Palliative Care to Them. In AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE, 2001, vol. 163, str. 2029-2032.
Foto: mdanderson.org

Preklad: Bc. Marta Nováková
Korektúra: Bc. Zuzana Zoláková

Poznámky:

1. Smedira NG, Evans BH, Grais LS, Cohen NH, Lo B, Cooke M, Schech- ter WP, Fink C, Epstein-Jaffe E, May C, Luce JM. Withholding and withdrawal of life support from the critically ill. N Engl J Med 1990; 322:309–315.
2. Prendergast TJ, Luce JM. Increasing incidence of withholding and with- drawal of life support from the critically ill. Am J Respir Crit Care Med 1997;155:15–20.
3. Prendergast TJ, Claessens MT, Luce JM. A national survey of end-of- life care for critically ill patients. Am J Respir Crit Care Med 1998;158: 1163–1167.
4. American Thoracic Society Bioethics Task Force. Withholding and with- drawing life-sustaining therapy. Am Rev Respir Dis 1991;144:726–731.
5. Luce JM. Ethical principles in critical care. JAMA 1990;263:696–700.
6. In re Quinlan, 755 A2A 647 (NJ), cert denied, 429 70 NJ 10, 355 A2d 647(1976).
7. Barber v Superior Court, 147 Cal App 3d 1006 (Cal App 1983).
8. Cruzan v Director, Missouri Department of Health, 497 US 261, 110 S Ct2841 (1990).
9. Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning and ethical implications. Ann Intern Med 1990;112:949–954.
10. Asch DA, Hansen-Flaschen J, Lanken PN. Decisions to limit or con- tinue life-sustaining treatment by critical care physicians in the United States: conflicts between physicians’ practices and patients’ wishes. Am J Respir Crit Care Med 1995;151:288–292.
11. Johnson SH, Gibbons VP, Goldner JA, Wiener RL, Eton D. Legal and institutional policy responses to medical futility. J Health and Hosp Law 1997;30:21–36.
12. In the Matter of Baby K. 16 F3d 590 (4th Cir 1994).
13. Gilgunn v Massachusetts General Hospital, No 92-4820 (Mass Super Ct Civ Action Suffolk So April 22, 1995).
14. Washington v Glucksberg, 521 US 702 (1997).
15. Vacco v Quill, 521 US 793 (1997).
16. Gostin LO. Deciding life and death in the courtroom: from Quinlan to Cruzan, Glucksberg, and Vacco—a brief history and analysis of constitutional protection of the “right to die.” JAMA 1997;278:1523–1528.
17. Burt RA. The Supreme Court speaks: not assisted suicide but a constitutional right to palliative care. N Engl J Med 1997;337:1234–1236.
18. Quill TE, Dresser R, Brock DW. The rule of double effect—a critique of itsrole in end-of-life decision making. N Engl J Med 1997;337:1768–1771.
19. Orentlicher D. The Supreme Court and physician-assisted suicide: re- jecting assisted suicide but embracing euthanasia. N Engl J Med 1997; 337:1236–1239.
20. Wilson WC, Smedira NG, Fink C, McDowell JA, Luce JM. Ordering and administration of sedatives and analgesics during the withholding and withdrawal of life support from critically ill patients. JAMA 1992; 267:949–953.
21. Asch DA. The role of critical care nurses in euthanasia and assisted sui- cide. N Engl J Med 1996;334:1374–1379.
22. Alpers A. Criminal act or palliative care? Prosecutions involving the care of the dying. J Law Med Ethics 1998;26:308–331.
23. Sullivan AD, Hedberg K, Fleming DW. Legalized physician-assisted sui- cide in Oregon—the second year. N Engl J Med 2000;342:598–604.
24. Pain Relief Promotion Act of 1999. HR 2260, 106th Congress, 1st ses- sion.
25. Angell M. Caring for the dying—congressional mischief. N Engl J Med 1999;341:1923–1925.
26. Bay Area Network of Ethics Committee (BANEC) Neighborhood Treat- ment Working Group. Nonbeneficial or futile medical treatment: con- flict resolution guidelines for the San Francisco Bay Area. West J Med 1999;170:287–292.
27. Keenan SP, Busche KD, Chen LM, McCarthy L, Inman KJ, Sibbald WJ. A retrospective review of a large cohort of patients undergoing the process of withholding and withdrawal of life support. Crit Care Med 1997;25:1324–1331.
28. Truog RD, Burns JP, Mitchell C, Johnson J, Robinson W. Pharmaco- logic paralysis and withdrawal of mechanical ventilation at the end of life. N Engl J Med 2000;342:508–511.




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