Where We Stand
Section: Hospice / End of Life Care / Death & Dying
Policy: Guidelines for the Withdrawal of Life-Sustaining Procedures Without a Directive to Physicians (Living Will)
Appendix G
The “Right to Die” Law is optional and does not require a physician to discontinue treatment.
There is a question whether the law applies to individuals who are under the age of 18. It is recommended by legal counsel that physicians treating patents under 18 should seek legal advice before withdrawal of life-sustaining procedures for those patients who otherwise meet the statutory qualifications set forth below.
Amendments to “Right to Die” Law
The new statute is intended to apply to a patient who is in a hospital or long term care facility (which includes a skilled nursing facility or an intermediate care facility) and who:
- Has had life-sustaining procedures instituted; and
- Has a terminal condition; and
- No reasonable possibility of returning to a cognitive sapient state; and
- Is comatose; and
- Has not executed a “Directive to Physicians.”
“Terminal condition” means an incurable condition caused by injury, disease or illness, which, regardless, of the application of life-sustaining procedures would, within reasonable medical judgment, produce death, and where the application of life-sustaining procedures serves only to postpone the moment of death of patient.
“Directive to Physicians” is a specific statutory form directing the withholding or withdrawal of life-sustaining procedures.
“Comatose” means: in a state of coma, i.e., a profound state of unconsciousness from which the person cannot be roused by stimulation.
“Cognitive sapient state” means that one does have those functions of the mind concerned with reasoning, understanding or being aware of the environment, objects of thought or perception.
*”Life-sustaining procedure” means any medical procedure or intervention that utilizes mechanical or other artificial means to sustain, restore or supplant a vital function of a person suffering from a terminal condition and serves only to artificially prolong the moment of death, or when death is imminent, whether or not such procedures are used.
*Note: “Life-sustaining procedures” do not include the usual care provided to individuals, which would include routine care necessary to sustain patient comfort and the usual and typical provisions of nutrition which, in the medical judgment of the attending physician, a patient can tolerate. This can be interpreted as providing the usual and customary feeding, bathing, turning, pain relief and other such patient care routines a facility normally provides a patient whether or not they meet the above conditions.
Once the attending physician determines a patient has met all of the above, then a committee must confirm the patient’s condition. This committee shall consist of two or more physicians other than the attending physician licensed by the Oregon Medical Board. This committee shall be appointed by the medical staff of the facility, or if the facility does not have an organized medical staff, the facility shall appoint such a committee.
Confirmation of the patient’s condition shall be documented and be made a part of the patient’s medical record.
A good faith effort shall be made by the attending physician to determine that the patient has not executed a “Directive to Physicians.” Such a good faith effort would include asking the patient’s family or other physicians who recently may have treated the patient. A memo of such inquiries should be documented in the medical record.
Once all of the above steps have been completed, the attending physician shall consult with the first of the following who can be reasonably located: (a) spouse; (b) guardian, if any; (c) a majority of the adult children; or (d) either parent.
The duty of locating the above is the facility’s. The steps taken to locate these persons should be document and communicated to the attending physicians.
The statute allows the first of the above to request to have life-sustaining procedures withdrawn. Wherever possible, get this request in writing signed by the person requesting. If this is not possible, get the best signature of make a memorandum of the situation. All documents shall be placed in the patient’s medical record.
While the statute only requires one of these persons to authorize withdrawal, if there appears to be a disagreement among the family members, request the family to resolve the problem among themselves before proceeding. This is the family problems – not that the physicians and hospital employees.
If there is serious doubt, a court order can be obtained, preferably sought by the family.
If all of the above procedures have been completed, documented and placed in the medical record, life-sustaining procedures may be withdrawn upon the direction and under the supervision of the attending physician.
If there are no family members or guardian of the patient, the attending physician may direct and supervise the withdrawal of life-sustaining procedures.
Physician Checklist
- No Directive to Physician has been executed.
- Is patient comatose?
- Is there no reasonable possibility that the person will return to a cognitive sapient state?
- Has the physician determined that the patient suffers from a terminal condition, as that term is defined in ORS 97.050(6)?
- Have life-sustaining procedures been implemented?
- Has the patient’s condition been confirmed by a committee of physicians appointed by the medical staff, or if none, appointed by the health facility?
- Has the health facility used and documented reasonable efforts to locate the family or guardian?
- Has the family or guardian requested the withdrawal of life-sustaining procedures?
- Has the request been documented?
If all of these questions can be answered affirmatively, then life-sustaining procedures can be withdrawn.
However, if the physician and health care facility must continue to provide routine care necessary to sustain patient comfort and the typical provision of nutrition which the physician believes the patient can tolerate.