The Hastings Center Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End of Life

Nancy Berlinger is a Research Scholar at The Hastings Center and teaches ethics in master's and doctoral programs at the Yale University School of Nursing. She directed the Hastings Center project that produced the revised edition of the Guidelines and is also the author of After Harm: Medical Error and the Ethics of Forgiveness (Johns Hopkins University Press, 2005). Her research and publications include topics in end-of-life care, palliative care, chronic illness, patient safety, and health policy. She serves on the bioethics committee at Montefiore Medical Center, Bronx, New York and is involved in clinician education in the New York area, nationally, and internationally. Bruce Jennings is Director of Bioethics at the Center for Humans and Nature and teaches ethics at the Yale School of Medicine. He has published widely on ethical issues in end-of-life treatment decision making and palliative care. He has served on the Board of Directors of the National Hopsice and Palliative Care Organization (NHPCO)and on numerous hospital ethics committees in the New York metropolitan areas. Susan M. Wolf is McKnight Presidential Professor of Law, Medicine & Public Policy at the University of Minnesota, as well as Founding Chair of the University's Consortium on Law and Values in Health, Environment & the Life Sciences, and a Faculty Member in the Center for Bioethics. She is an elected Member of the National Academy of Science's Institute of Medicine, elected Fellow of the AAAS, and elected Fellow of The Hastings Center. She directed the Hastings Center project that produced the first edition of the Guidelines in 1987, and was principal author of that work.

Preface to the Second Edition ; Contributors ; How These Guidelines Are Organized ; Introduction ; The Function and Sources of These Ethics Guidelines ; Legal and Ethical Consensus Informing These Guidelines: Rights, Protections, and Key Philosophical Distinctions ; Part One: Framework and Context ; Section 1: Ethics Goals for Good Care When Patients Face Decisions about Life-Sustaining Treatment or Approach the End of Life ; Section 2: Ethics Education Competencies for Health Care Professionals Caring for Patients Facing Decisions about Life-Sustaining Treatment and Patients Approaching the End of Life ; Section 3: Organizational Systems Supporting Good Care and Ethical Practice ; Section 4: Social, Economic, and Legal Contexts ; A. Social Context ; B. Economic Context ; C. State and Federal Context ; Part Two: Guidelines on Care Planning and Decision-Making ; Section 1: Guidelines for Advance Care Planning and Advance Directives: Using Patient Preferences to Establish Goals of Care and Develop the Care Plan ; Section 2: Guidelines for the Decision-Making Process ; A. Evaluating the Patient ; B. Determining Decision-Making Capacity ; C. Identifying the Key Decision-Maker ; D. Surrogate Decision-Making ; E. Making the Decision at Hand ; F. Documenting the Decision ; G. Implementing the Decision ; H. Changing Treatment Decisions ; I. Conflict and Challenges Related to Treatment Decision-Making ; Section 3: Guidelines Concerning Neonates, Infants, Children, and Adolescents ; A. General Guidelines for Pediatric Decision-Making Concerning the Use of Life-Sustaining Treatments ; B. Guidelines for Decision-Making and Care Involving Nonviable Neonates and Neonates at the Threshold of Viability ; C. Guidelines for Decision-Making about Life-Sustaining Treatment for Viable Neonates ; D. Guidelines for Decision-Making about Life-Sustaining Treatment for Young Children ; E. Guidelines for Decision-Making with Older Children ; F. Guidelines for Decision-Making with Adolescents ; G. Guidelines for Decision-Making by Mature Minors and Emancipated Minors ; Section 4: Guidelines for Care Transitions ; A. General Guidelines for Hand-Offs between Professionals and Transfers across Care Settings ; B. Guidelines on Care Transitions for Nursing Home Residents ; C. Guidelines on Portable Medical Orders ; D. Guidelines on Discharge Planning and Collaboration with Nursing Homes, Home Care, Hospice, and Outpatient Care ; E. Guidelines on Care Transitions for Patients Who Will Die in the Hospital ; Section 5: Guidelines for the Determination of Death ; A. Procedural Guidelines for Making a Determination of Death and for Making a Declaration of Death ; B. The Determination of Death: Continuing Ethical Debates ; Section 6: Guidelines for Institutional Policy ; A. Guidelines on Ethics Services in Institutions Providing Care for Patients Facing Decisions about Life-Sustaining Treatment or Approaching the End of Life ; B. Guidelines on Palliative Care Services ; C. Guidelines Supporting Advance Care Planning ; D. Guidelines Supporting Portable Medical Orders ; E. Guidelines Supporting Care Transitions ; F. Guidelines on the Role of Institutional Legal Counsel and Risk Management in Supporting Good Care ; G. Guidelines on Conflict Resolution ; Part Three: Communication Supporting Decision-Making and Care ; Section 1: Communication with Patients, Surrogates, and Loved Ones ; A. Conducting a Family Conference When a Patient's Condition Is Deteriorating ; B. Supporting the Decision-Maker When Loved Ones Disagree ; C. Discussing Values Concerning Nutrition and Hydration ; D. Using Electronic and Telephone Communications with Seriously Ill Patients or with Surrogates and Loved Ones ; Section 2: Communication and Collaboration with Patients with Disabilities ; A. Life-Sustaining Treatments and Accommodation of Stable or Progressive Disabilities ; B. Communication When a Patient's Disability Affects Speech ; C. Communication When a Patient's Disability Affects Cognition ; D. Communication and Collaboration with Recently Disabled Patients Concerning Life-Sustaining Treatments ; Section 3: Psychological Dimensions of Decision-Making about Life-Sustaining Treatment and Care Near the End of Life ; A. Coping as a Factor in Treatment Decision-Making ; B. Hope as a Factor in Treatment Decision-Making ; C. Ambivalence, Denial, and Grief as Factors in Treatment Decision-Making ; D. Existential Suffering as a Factor in Treatment Decision-Making ; E. Spirituality and Religion as Factors in Treatment Decision-Making ; F. Religious Objections during Treatment Decision-Making ; G. Moral Distress as a Factor in Treatment Decision-Making ; H. Integrating Bereavement Care for Loved Ones and Professionals into Care Near the End of Life ; Section 4: Decision-Making Concerning Specific Treatments and Technologies ; A. Forgoing Life-Sustaining Treatments: Ethical and Practical Considerations for Clinicians ; B. Brain Injuries and Neurological States ; C. Mechanical Ventilation ; D. Cardiopulmonary Resuscitation and Cardiac Treatments ; E. Dialysis ; F. Nutrition and Hydration ; G. Chemotherapy and Other Cancer Treatments ; H. Routine Medications, Antibiotics, and Invasive Procedures ; I. Blood Transfusion and Blood Products ; J. Palliative Sedation ; Section 5: Institutional Discussion Guide on Resource Allocation and the Cost of Care ; A. Developing a Practice of Discussing Resource Allocation and the Cost of Care: Six Strategies ; B. Discussing Uncompensated Care for Patients without Insurance ; Glossary ; Cited Legal Authorities ; Selected Bibliography ; Index