Medicolegal aspects of end-of-life care - consent

Principles

Consent principles for end-of-life care follow the same fundamental framework as consent generally (capacity, information, voluntariness) but apply to decisions with unusually high stakes - treatment withdrawal, resuscitation status, and symptom control that may hasten death as a foreseen but unintended effect
Consent discussions near the end of life are common but frequently occur later than ideal, often during an acute deterioration when the patient's capacity is already compromised

A patient with capacity has the right to refuse any treatment, including life-sustaining treatment, even if the clinical team disagrees with that choice - this is a well-established legal and ethical principle, not a matter of clinical discretion once capacity and informed refusal are established

Where capacity is lacking, consent for ongoing/altered treatment falls to a substitute decision-maker (or is guided by a valid advance care directive) following the same framework as consent for any other decision in an incapacitated patient
Consent for treatments intended for symptom relief (e.g. opioids, sedatives) that carry a foreseeable but unintended risk of hastening death should be obtained with clear explanation of this risk, framed honestly within the doctrine of double effect (see beneficence versus non-maleficence)

Document the consent discussion and the patient's (or substitute decision-maker's) understanding clearly, particularly for decisions with significant consequences (treatment withdrawal, resuscitation status)
Revisit consent as the clinical situation evolves - an earlier consent discussion does not necessarily cover a subsequently changed treatment plan

Capacity assessment, advance care directives, substitute decision-making, the doctrine of double effect

A common misconception is that "doing everything" is the safe legal default - in fact, providing unwanted treatment against a capacitous patient's clearly expressed refusal, or against a valid advance care directive, itself carries legal and ethical liability

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