In 1991, the American Nurse Association stated that it is ethically justified to give pain medication to achieve control of pain, even at the expense of life. Additionally, in 1997 the United States Supreme Court differentiated palliation from assisted suicide, noting that the use of sedation to ease suffering when people are near death is appropriate.

In an effort to improve pain management, the state of West Virginia has enacted limitation on disciplinary sanctions or criminal punishment related to management of intractable pain. Nurses "shall not be subject to disciplinary sanctions by a licensing board or criminal punishment by the state for administering pain-relieving controlled substances to alleviate or control intractable pain, if administered in accordance with the orders of a licensed physician." Many other states have also sought to protect medical professionals by enacting similar laws. Knowing your state's laws will enable you to confidently assist patients to manage their pain.

Virtually all authorities agree that addiction is not a matter of concern in end of life care. It's helpful to remember that whether the patient dies in pain or in comfort, the patient is dying, and that can't be reversed. However, death can occur without suffering, and that can be ensured by appropriate palliative care. It's helpful to everyone concerned if the patient completes an advance directive. Then, family, as well as healthcare providers, know that the treatment they are providing is what the patient wants.

People need to give careful consideration to the way they want their health care managed, if they become no longer able to make decisions or convey their wishes. This requires planning for the end of life before death is imminent. People are often proactive about completing estate planning and having a valid will, but they also need to plan ahead for the end of life, and they need to communicate their wishes to their families, physicians, and others to whom they are close. One problem with only "stating" wishes is that, if a person becomes unable to speak for him/herself, decisions about health care may be made by family members or others who have a different perspective. The family member, or designate, may not be able to bring him/herself to assume responsibility for discontinuing treatment, even if that is what the patient previously stated.

"Advance directive" is a general term used to describe oral or written instructions by an individual expressing wishes about future medical care, if the time comes that they are unable to speak for themselves. Competent adults have the right to determine the course of their own care, including the right to refuse medical treatment, or to outline the type of treatments that they do or do not want. An example of such treatment is, what is commonly referred to as life support, which is defined as "any mechanical device that enables a person to live...in an environment...in which he could not otherwise function or survive for any appreciable amount of time..."

They may also state their desire to donate their body or body parts. Having an advance directive in place is the only way a person can be reasonably sure that his or her wishes will be known and respected. Advance directives must be in this format:

• In writing
• Signed by the individual
• Witnessed
• Compliant with state laws; there are slight variations from one state to another
• Copies of advanced directives should be given to the following individuals:
  • Family members
  • Physician
  • Lawyer
  • Clergy
  • Close friends
    

In Florida, as in most states, the individual's wishes may be communicated in three ways: Living will, health care surrogate, and durable power of attorney. Many people have a combined living will/health care surrogate. In that case, it's very important that the person has discussed the contents of the living will in detail with the designated health care surrogate and that the surrogate understands and agrees to abide by the persons wishes:

• Living will
• Health care surrogate
• Durable power of attorney
  

Living will:

A living will outlines the care that is to be given or withheld if the person becomes incapacitated or unable to make his or her own decisions about end of life care. Many living wills include “do not resuscitate” orders (DNRO) that specifically describe the circumstances under which the individual does not wish to be resuscitated. Individuals should give careful thought to the living will and be as detailed as possible, including such details as a desire for pain control and whether or not the person would prefer pain control to consciousness. Leaving ambiguous directions about “quality of life” can lead to various interpretations.

Health care surrogate:

Many people believe that if they have a living will or advance directive they don't need to assign a health care surrogate to make decisions about their care if they are unable to do so. However, critical decisions that are not covered by the living will often need to be made. If a health care surrogate is not assigned by the individual, and the person is not able to express his or her desires, then the laws of the state take over and someone is allowed to make those decisions. The normal order is this:

• Court-appointed guardian
• Spouse or parent (for minor child)
• Child
• Parent or Sibling
• Other relative
• Friend
  

The prolonged court battle that ensued between the spouse of Teri Schiavo and her parents, over the spouse's decision to stop supportive treatments, is a prime example of what can happen if people do not make their wishes clear about end of life issues. Even members of the same family may have profound disagreements. It is the responsibility of the health care surrogate to advise the physician of the patient's wishes.

Durable power of attorney:

A durable power of attorney can delegate the authority to make health, financial, and/or legal decisions on a person's behalf. Therefore, it can be broader than a living will. The durable power of attorney can be in effect while the person is able to make decisions, but also remains in effect when the person is not. It must be in writing and must show the person's intent to give specified power if the person is incapacitated. It must specifically state that the designee can make health care decisions. A durable power of attorney is especially important if a person is in the early stages of dementia and is expected to lose the ability to make his or her own decisions. In this case, he/she wishes to designate the authority to make decisions about many issues, including finances, to someone trusted.

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