Almanac of Policy Issues: Criminal Justice #criminal #justice #policies #list, #public #policy

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Criminal Justice

Crime in the United States has declined substantially in recent years. Homicide, robbery, rape, and assault have all dropped sharply since highs in the early 1990s. Substance abuse has declined less sharply, however, and drug-related arrests have actually increased steadily, reaching record highs over the past few years. The number of people under some form of correctional supervision, meanwhile, has also continued to reach new highs. In 1996, over 5.5 million Americans (or about 2 percent) were in prison, jail, on probation or parole.

While criminologists (and, indeed, most Americans) agree that more needs to be done to lower the national crime rate, there are sharp differences over how this should be accomplished. Some believe that tougher enforcement policies should be pursued, including increased spending on law enforcement and prison facilities, longer sentences for offenders, and stepped up use of the death penalty for the worst crimes. Others argue that more money needs to be spent on prevention, including social services and education, to provide hope and opportunity for potential offenders.

This section examines all of these issue in depth.

RELATED SITES, ISSUES ARTICLES

  • Political Magazines. The Almanac’s links to political and public policy magazine sites.
  • Public Policy Jobs. Sites listing public policy, lobbying, and media jobs in government and at major national organizations.
  • Questia. Search over 400,000 books and journals at Questia online.

Directories

  • American Bar Association. Voluntary professional association of US attorneys.
  • Cato Institute – Criminal Justice and Law Enforcement. Promoting an American public policy based on individual liberty, limited government, free markets and peaceful international relations. Extensive library of studies, articles and monographs available
  • Center for Court Innovation. Information about problemsolving courts, such as drug courts, community courts and mental health courts, which seek to improve case outcomes for communities and litigants.
  • Equal Justice USA. Seeks to bring into clear focus the racial, economic and political biases active in U.S. courts, prisons, jails and policing agencies, and to expand public opposition to the death penalty.
  • Heritage Foundation – Crime
  • Impact of a Criminal Record. Information about the effects of a criminal record on such matters as voting rights, employment, pensions, and ability to obtain a license.
  • Miranda Rights. News and resources on the history and fate of the warnings given while being arrested.
  • National Consortium for Justice Information Statistics
  • National Criminal Justice Reference Service. Lists publications and links on corrections, courts, crime, drugs, international crime, juvenile justice, law enforcement, research, statistics, crime victims.
  • National Institute of Corrections
  • Progressive Policy Institute – Crime & Public Safety
  • Supreme Court Decisions. FindLaw for Legal Professionals is a free resource for attorneys that includes online case law, free state codes, free federal codes, free legal forms, and a directory of products and services for lawyers. This online legal Web site also includes a legal career center.
  • Urban Institute – Justice

Articles

  • Check and Credit Card Fraud (US Department of Justice: September 30, 2003) — PDF File
  • Family Violence (National Criminal Justice Reference Service: Added August 7, 2003)
  • Criminal Victimization: 2002 (US Bureau of Justice Statistics: August, 2003)
  • Crime Control: The Federal Response (Congressional Research Service: September 12, 2002)
  • Identity Theft: Growing Prevalence and Cost (General Accounting Office: February 14, 2002)
  • Domestic Violence (U.S. Department of Health and Human Services: April, 2000)
  • Sourcebook of Criminal Justice Statistics (U.S. Department of Justice: provided through State University of New York at Albany)




Cloud Computing Security Training, Certification – Institute of Information Security, Mumbai(India) #cloud

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QUICK LINKS

Cloud computing is the use of hardware and software resources that are delivered as a service typically over the Internet. It entrusts remote services with user’s data, software and computation.

Although there are numerous business advantages and opportunities offered by cloud computing in terms of improved availability, scalability, flexibility etc. it is important to tap its business potential carefully. Securing the client data in the “cloud” must be the prime concern for the cloud service provider. Legal concerns over jurisdiction of client data in “cloud” needs to be addressed properly. This is because the stored data may not reside with service provider in its own data center or at a single location.

In this course, we shall first discuss the characteristics of cloud computing and later on focus specifically on cloud security’s best practices taking reference from industry standards like NIST, OWASP, Cloud Security Alliance etc. We then look into the broad set of policies, technologies, and controls deployed to protect client data, applications and infrastructure associated with cloud computing.

Who should attend?

  • Business Owners
  • Entrepreneurs
  • Senior Managers
  • Cloud solution providers
  • Business Analysts
  • Developers
  • Compliance managers
  • Security Enthusiasts

Course Contents

Session One: Cloud Knowledge Foundation
  • Introduction to cloud
  • History of Cloud Computing
  • Architectural Overview
  • Security Architecture
  • Terms & Terminologies
  • Cloud Deployment Types
    • Public Cloud
    • Private Cloud
    • Hybrid Cloud
    • Community Cloud
  • Service Model Types
    • Software As Service
    • Platform As Service
    • Infrastructure As Service
  • Some Real-world Cloud scenarios – Case Studies
Session Two: Knowing Cloud Vendors – Demos




CV dos and don ts #associate #professor,gradpsych,job #market,professional #development,workforce #analysis,,curriculum #vitae, #job

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CV dos and don’ts

What type of curriculum vitae (CV) is most likely to impress potential employers? One that is simple, straightforward, organized and tailored to fit a job ad, experts say.

“Right now it’s a very competitive job market, and a CV is your ticket to an interview,” says Tara Kuther, PhD, an associate professor of psychology at Western Connecticut State University who has given seminars on writing CVs. “A vitae that is formatted nicely, attractive, looks professional and presents your strengths really stands out to employers.”

As such, putting together your CV takes much care and forethought. First off, be sure the job asks for a vitae and not a résumé. A vitae is a detailed record that showcases your career and education accomplishments and can be unlimited in length, whereas a résumé is generally a one-page overview of your career. When applying for most jobs in psychology, employers will request that you send a vitae, not a résumé.

Also, depending on the type of job you are applying for-a practice or academic one-you might need to tailor your vitae. When applying for a practice job, highlight your internship and practicum experience, experts recommend. On the other hand, when applying for an academic or research job, highlight your publications, teaching and research experiences, they say.

Here are the essentials of a vitae that impresses:

Organize your vitae with sections such as “education,” “professional experience” and “publications,” and list each accomplishment in chronological order with beginning and end dates. Also, if applicable, include sections such as “practica/psychotherapy experience,” “volunteer/service work,” “awards and scholarships” and “professional affiliations.”

When applying for a practitioner job, include a section on assessment measures you have mastered during training, advises Shawn Roberson, PhD, a forensic psychologist at the Oklahoma Forensic Center, part of the Northeastern Psychology Internship Program. Roberson helps to screen internship applicants at the center.

WEIGHT IF IT’S WORTH INCLUDING

What to include depends on what the position entails, experts say. For instance, should you include coursework? Most advisers say no, but some recommend listing any specialized training-you might include coursework in forensic psychology, for example, when applying for a forensic job. However, experts generally say that coursework, methodological skills and software proficiencies should be omitted from a vitae that’s geared for full-time jobs, since it’s assumed that psychologists have mastered these skills. Still, you might include such skills on applications for internship and postdoctoral positions, they note.

In particular, any undergraduate experiences you include should be highly relevant to your psychology career and the job at hand, says Mary Kite, PhD, associate dean of the Graduate School at Ball State University and a professor of psychological science there. While social fraternities and sororities don’t belong on a vitae, students might note membership in Psi Chi or Phi Beta Kappa and high academic honors, such as magna cum laude, Kite says.

Be creative in relating your experiences to the job, Roberson adds. If the position requires public speaking or organizational involvement, you might, for example, highlight your work with organizational boards. Experts also say you should not include your age, relationship status or hobbies on your CV.

KEEP IT SIMPLE AND STRAIGHTFORWARD

Too often students try to cram too much information on a page, Kite says. Keep job descriptions clear and concise, and follow a standard format. Bold the headers of the different sections-such as education and professional experience-and use a simple font such as Times New Roman, experts recommend. Also, use quality white or ivory paper, Kite advises. These steps will help employers easily absorb the information on your CV.

HONESTLY REPRESENT YOUR WORK

Don’t pad your vitae to make it appear more impressive, experts advise. For example, Kuther says, many students lump publications and presentations together to make the section look longer. But search committees usually prefer to see them separate, she says. “Everyone understands you’re a student,” Kuther explains. “If you only have one [published] article listed, that is still a fantastic thing.”

TAILOR YOUR VITAE TO THE JOB

Match your background, skills and training to the job you’re applying for, Roberson says. For example, clinical psychologists need to emphasize internship and supervision experience, while academic applicants need to highlight research and teaching experience, Kite adds. “If a student is looking for both, then they should have two different vitae rather than a one-size-fits-all vitae,” Kite says.

MAXIMIZE YOUR CV WITH THE COVER LETTER

Use the cover letter to highlight accomplishments on your CV, such as clinical, research or education experiences that match the job, Roberson notes. You can also call attention to work that doesn’t belong in the CV: If you have any research in progress, for instance, use the cover letter to mention it, Kite says. The CV should only contain research that has been published or is in press, she explains. And, just like the CV, the cover letter also needs to be customized for every employer.

Ask colleagues or faculty members to check your vitae for awkward phrasing, formatting problems and spelling errors, and to give you feedback on content and organization, advise Kite and others.

Ultimately, the vitae should serve as a summary of your education and career experiences, Kite notes, and should be continually updated throughout your career.

The Vitae Checklist

Name and contact information. including work and home phone numbers, address and e-mail





APA Resolution on End-of-Life Issues and Care #cheap #hotels #near #me

#end of life care issues

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APA Resolution on End-of-Life Issues and Care

Whereas the nature of dying and death has changed across the twentieth century, occurring primarily in an institutional setting rather than at home (Benoliel Degner, 1995); and

Whereas death has become more frequently the result of chronic illness (Battin, 1996); and

Whereas medicine and technology have evolved to the point where the terminal period can be significantly prolonged (Field Cassel, 1997); and

Whereas there are many more people living longer with terminal diagnoses and thus having more time to make end-of-life decisions; and

Whereas end-of-life decision-making is complex, involving areas of ethics, religion, medicine, psychology, sociology, economics, the law, public policy, and other fields; and

Whereas the population of the United States is aging, resulting in larger numbers of people who may request psychological support in making end-of-life decisions; and

Whereas in the United States there is significant social stratification related to cultural, ethnic, economic, gender, and religious differences; and

Whereas this diversity in our society leads to an equally diverse range of views regarding end-of-life care and decisions;

Whereas reasonable, well-informed people starting from different values and priorities concerning what is valuable at the end of life can and do hold different positions regarding end-of-life care and decisions; and

Whereas autonomy is an important guiding principle in the law and in medical, ethical, and psychological aspects of decision-making, but in and of itself is insufficient to capture the full range of complex medical, familial, social, financial, psychological, cultural, spiritual, and legal issues involved in end-of-life decision-making; and

Whereas there is increasing public support for control over end-of-life decisions but this support is weakest among groups who express concerns about being pressured to die (i.e. older adults, people with less education, women, and ethnic minorities) (Blendon, Szalay, Knox, 1992); and

Whereas in the United States medical end-of-life decisions are made in a context of serious social inequities in access to resources such as basic medical care; and

Whereas some evidence suggests that there are fluctuations in the will to live (Chochinov, Tataryn, Clinch, Dudgeon, 1999) and in wishes regarding life-sustaining treatments (Weisman, Haas, Fowler, 1999); and

Whereas pain and clinical depression are frequently under-treated, which can lead to suffering that may result in requests for, or assent to, medical interventions that affect the timing of death (Foley, 1995); and

Whereas more people are aware of the possible benefits to be gained by using psychological services to help them make end-of-life decisions; and

Whereas psychology has been largely invisible in the end-of-life arena; and

Whereas psychologists have many areas of competence, including assessment, counseling, teaching, consultation, research, and advocacy skills that could potentially contribute to the science of end-of-life care and to the treatment and support of dying persons and their significant others; and

Whereas psychological research on end-of-life issues is limited in comparison with the magnitude of the issue; and

Whereas there have been no systematic efforts to educate psychologists about end-of-life issues; and

Whereas psychologists in clinical practice have not typically been involved in end-of-life decisions to the degree that they could be; and

Whereas psychologists could assume a significant role in helping health care providers to understand and cope with the concerns and needs of dying individuals and their families; and

Whereas psychologists could be instrumental in supporting public education efforts to raise awareness of issues related to dying, death, grief, mourning, and loss;

Therefore, be it resolved that the American Psychological Association, an organization committed to promoting the psychological well-being of individuals across the life span, should redress psychology’s historical under-commitment to end-of-life care by actively promoting and supporting psychology’s involvement in end-of-life care. In order to advance this involvement, be it further resolved that the American Psychological Association:

Promote and encourage research and training in the area of end-of-life issues within psychology programs at all levels; and

Encourage and promote the development of a research agenda on end-of-life issues; and

Support efforts to increase funding for research associated with end-of-life issues; and

Encourage psychologists to obtain training in the area of ethics as it applies to end-of-life decisions and care; and

Promote and facilitate psychologists’ acquisition of competencies with respect to end-of-life issues, including mastery of the literature on dying and death and sensitivity to diversity dimensions that affect end-of-life experiences; and

Encourage practicing psychologists to be aware of their own views about the end of life, including recognizing possible biases about entitlement to resources based on disability status, age, sex, sexual orientation, or ethnicity of the client making end-of-life decisions; and

Encourage psychologists to be especially sensitive to the social and cultural biases which may result in some groups and individuals being perceived by others, and/or being encouraged to perceive themselves, as more expendable and less deserving of continued life (e.g. people with disabilities, women, older adults, people of color, gay men, lesbians, bisexual people, transgendered individuals, and persons who are poor); and

Support interdisciplinary efforts to increase the competency of psychologists and other health care professionals in end-of-life issues; and

Promote quality end-of-life care including palliative care, access to hospice services, support for terminally ill people and family members, accurate assessment of depression and cognitive capabilities of dying persons, and assistance with end-of-life decision-making; and

Advocate for access to, and reimbursement for, professional mental health services for seriously ill individuals and their families; and

Promote and support public policies that provide for the psychosocial services for dying individuals and their families; and

Support psychologists who wish to participate in ethics committees dealing with end-of-life issues; and

Support psychologists as they work cooperatively with caregivers, medical providers, and multidisciplinary teams to enhance understanding of the psychological aspects of dying and death and to improve quality of care for the dying; and

Endorse the following principles on end-of-life care as articulated in the Institute of Medicine Report entitled Approaching Death: Improving Care at the End of Life (Field Cassel, 1997):

  • Care for those approaching death is an integral and important part of health care;
  • Care for those approaching death should involve and respect both patients and those close to them;
  • Good care at the end of life depends on clinicians with strong interpersonal skills, clinical knowledge, technical proficiency, and respect for individuals, and it should be informed by scientific evidence, values, and personal and professional experience;
  • The health community has a special responsibility for educating itself and others about the identification, management, and discussion of the last phase of fatal medical problems;
  • More and better research [in the areas of biomedical, clinical, psychosocial, and health services] is needed to increase our understanding of clinical, cultural, organizational, and other practices or perspectives that can improve care for those approaching death;
  • Changing individual behavior is difficult, but changing a culture or an organization is potentially a greater challenge — and often is a precondition for individual change.

References

Battin, M. P. (1996). The death debate: Ethical issues in suicide (pp. 175-203). Upper Saddle River, NJ: Prentice-Hall.

Benoliel, J .Q. Degner, L. F. (1995) Institutional dying: A convergence of cultural values, technology, and social organization. In H. Wass R. A. Neimeyer (Eds.) Dying: Facing the facts (pp. 117-141). Washington, DC: Taylor and Francis.

Blendon, R. J. Szalay, U. S. Knox, R. A. (1992). Should physicians aid their patients in dying? The public perspective. Journal of the American Medical Association, 267, 2658-2662.

Chochinov, H. M. Tataryn, D. Clinch, J. J. Dudgeon, D. (1999). Will to live in the terminally ill. Lancet, 354, 816-819.

Field, M. J. Cassel, C. K. (Eds.). (1997). Approaching death: Improving care at the end-of-life. Washington, DC: National Academy Press.

Foley, K. M. (1995). Pain, physician-assisted suicide, and euthanasia. Pain Forum, 4, 63-178.

Weisman, J. S. Haas, J. S. Fowler, F. J. (1999). The stability of preferences for life sustaining care among persons with AIDS in the Boston Health Study. Medical Decision Making, 19, 16-26.

End-of-Life Decisions – End of Life Issues – California Medical Association #eurodisney

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End-of-Life Decisions

California law provides individuals the ability to ensure that their health care wishes are known and considered if they become unable to make these decisions themselves.

The California Medical Association (CMA) encourages Californians to think and talk with loved ones about their wishes for end-of-life medical care before a serious illness or injury occurs. CMA has developed a number of guidelines, forms, and other resources to assist providers, patients, and loved ones with making important end-of-life decisions.

NEW! California s End Of Life Option Act

On October 5, 2015, California became the fifth state in the nation to allow physicians to prescribe terminally ill patients medication to end their lives. ABX2-15, the “End of Life Option Act,” permits terminally ill adult patients with capacity to make medical decisions to be prescribed an aid-in-dying medication if certain conditions are met. The following document discusses the requirements under the End of Life Option Act, which went into effect June 9, 2016:

  • CMA On-Call #3459: The California End of Life Option Act
  • On-demand webinar: The California End of Life Option Act: An Overview

Advance Health Care Directive

In California, advance directives are the legally recognized format for living wills. An advance directive enables individuals to make sure that their health care wishes are known in advance and considered if for any reason they are unable to speak for themselves. Advance directives also allow patients to appoint a health care “agent” who will have legal authority to make health care decisions in the event that the patient is incapacitated, or immediately upon appointment if the patient expressly grants such authority.

See below for more information about advance directives, or to purchase CMA’s Advance Health Care Directive Toolkit, available in English and Spanish:

  • CMA Advance Health Care Directive Kit in English (rev. 3/14)
  • CMA Advance Health Care Directive Kit in Spanish (rev. 9/14)
  • CMA On-Call #3451. Decisions Regarding Life-Sustaining Treatment – Advance Directives and POLST (2015)
  • CMA On-Call #3450. Decisions Regarding Life-Sustaining Treatment for Patients Without Advance Directive or POLST (2015)

Physician Orders for Life-Sustaining Treatment

Physician Orders for Life Sustaining Treatment (POLST) in 2009 became a legally recognized document, similar to the widely used do not resuscitate (DNR) orders. The POLST form, used for patients with a serious illness or whose life expectancy is a year or less, outlines a plan of care reflecting the patient s wishes concerning medical treatment and interventions at life s end. The POLST form complements an advance directive by turning a patient s treatment preferences into actionable medical orders.

See below for more information about POLST, or to purchase CMA’s POLST toolkit, available in English and Spanish:

  • 2016 POLST form (effective January 1, 2016)
  • CMA POLST Kit in English (rev. 12/15)
  • CMA POLST Kit in Spanish (rev. 10/14)
  • CMA On-Call #3451. Decisions Regarding Life-Sustaining Treatment – Advance Directives and POLST (2015)
  • CMA On-Call #3450. Decisions Regarding Life-Sustaining Treatment for Patients Without Advance Directive or POLST (2015)

Do Not Resuscitate (DNR) Form

The Pre-Hospital DNR form, developed by the California Emergency Medical Services in conjunction with the California Medical Association, instructs EMS personnel to forgo resuscitation attempts in the event of a patient’s cardiopulmonary arrest. Below you will find CMA resources that include additional details about DNR requests and purchasing information for the DNR form in English and Spanish.

  • Do Not Resuscitate Form in English
  • Do Not Resuscitate Form in Spanish
  • CMA On-Call #3453. Decisions Regarding Resuscitative Measures DNR Requests Orders and Cardiopulmonary Resuscitation (2015)

Other Resources

CMA’s Health Law Library
Updated annually, CMA’s online health law library contains nearly 5000 pages of valuable information for physicians and their staff. The CMA Center for Legal Affairs has developed several On-Call documents on important end-of-life issues in the medical practice. Access to the library is FREE to members. Nonmembers can purchase documents for $2 per page.

  • On-Call #3452. Documenting Decisions Regarding Life-Sustaining Treatment
  • On-Call #3454. Decisions Regarding Life-Sustaining Treatment and the Patient Self-Determination Act and Joint Commission
  • On-Call #3455. Physician-Assisted Suicide
  • On-Call #3456. Responding to Request for Non-Beneficial Treatment
  • On-Call #3458. CMA Model Policy: Responding to Requests for Non-Beneficial Treatment
  • On-Call #3400. Autopsies
  • On-Call #3401. Organ and Tissue Donation
  • On-Call #3402. Pronouncement of Death and Death Certificates
  • On-Call #3403. Pronouncement of Death Diagnosis of Death by Neurologic Criteria

For Patients
For more information about end-of-life medical decisions, visit the Coalition for Compassionate Care of California (CCCC) website, www.coalitionccc.org.

The booklet Finding Your Way was written by the Center for Healthcare Decisions as a useful guide to thinking about and discussing end-of-life issues. To order a copy, visit the CCCC website or call the organization at (916) 489-2222.

If you have a serious medical condition or have been diagnosed with a terminal illness, CMA encourages you to talk to your doctor about POLST. Before initiating that conversation, you may wish to visit www.capolst.org or the California Coalition for Compassionate Care website for more information.

For Providers
End-of-life resources for health care providers are available at the Coalition for Compassionate Care of California website. CCCC also provides decision guides. palliative care tools and resources for physicians.

End-of-Life Issues: Ethical Topic in Medicine #midwest #palliative #& #hospice #carecenter

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End-of-Life Issues

A s care of the dying involves so much of one’s self, in this topic page I will describe my approach as an one example of how clinicians think about end-of-life care. I remember, the first time one of my patients died, feeling a chill of horror and fascination. I wasn’t prepared for it. The resident yawned–a long night, then a long code. “We better go talk to the family.” What in the world would we say? The dead patient, now dusky blue, looked unreal and unfamiliar. I was so wrapped up in my own feelings that I can’t recall much else.

Now I find care of the dying to be one of the richest parts of my clinical life. But it is demanding in a different, more personal way, than, say, treating pneumococcal pneumonia with penicillin. Here I will describe some ways of thinking about care of the dying that have helped me figure out where I am going as I guide someone who is really sick.

Many medical students first encounter care of the dying as an unsuccessful code or a strategic withholding of CPR. Of course, an ethically sound understanding of withdrawing and withholding treatment is crucial to good care of the dying. Yet “withholding and withdrawing” only describe what we, as clinicians, decide not to do. To provide excellent care of the dying requires that we also decide what we should do. What should be the goals of medical care for people who are dying? What makes a good death?

What is a “good death”? A medical perspective

The good death is not a familiar idea in American culture. Some experts in palliative care describe the United States as a “death-defying” culture, with a mass media that spotlights only youth and beauty. Yet public interest in care of the dying is currently high. The striking public interest in physician aid-in-dying is one obvious reason. But there are other reasons: over the past 100 years, there has been a epidemiologic shift in the reasons people die. In the pre-antibiotic era, people most often died young, of infectious diseases; now, thanks to medical technology, most Americans (and others with access to this technology) live much longer, to die of degenerative, neoplastic, and even man-made diseases. Finally, there is a marked public fear that a medical death, depicted in TV shows like “ER” as an unresponsive, uncommunicative body hooked up to an array of flashing monitors, represents an irresponsible use of technology and a dishonorable way to treat a person.

Interestingly, contemporary medical literature contains little that might characterize what makes a death “good.” Recently, a large, expensive empirical study of intensive care unit deaths suggested that medical care for a common type of in-hospital death is “bad” (the SUPPORT study, referenced below). In this study of dying patients, severe pain was common, decisions to withhold invasive treatments were made at the last minute, and physicians often had no knowledge of patient preferences not to have CPR. Even worse, an intervention designed to provide physicians with better prognostic information had no effect on medical decision making prior to death. While the SUPPORT authors did not actually describe these deaths as “bad,” we could certainly agree that they were not “good deaths.”

In caring for a person who is dying, knowing what would make the experience of dying “good” is an important goal for physicians and other members of the care team. I find it doesn’t take fancy techniques-you just need to be sincere and patient and interested. Listen more and talk less. Try asking something like, “Knowing that all of us have to think about dying at some point, what would be a good death for you?” What people choose when they think about a good death for themselves is often beyond what medicine can provide-for instance, an affirmation of love, a completion of important work, or a last visit with an important person. As a physician, I can’t always make those things happen. But I can help the dying person get ready-and in this way, contribute to a death that is decent.

What goals should I have in mind when working towards a decent death for my patient?


I have several working clinical goals when I am caring for someone near the end of life. I work towards:

  1. Control of pain and other physical symptoms. The physical aspects of care are a prerequisite for everything that follows.
  2. Involvement of people important to the patient. Death is not usually an individual experience; it occurs within a social context of family, significant others, friends, and caregivers.
  3. A degree of acceptance by the patient. Acceptance doesn’t mean that the patient likes what is going on, and it doesn’t mean that a patient has no hopes–it just means that he can be realistic about the situation.
  4. A medical understanding of the patient’s disease. Most patients, families, and caregivers come to physicians in order to learn something about what is happening medically, and it is important to recognize their need for information.
  5. A process of care that guides patient understanding and decision making. One great physician does not equal great care–it takes a coordinated system of providers.

How do you know when someone is dying?

This question is not as simple as it might sound. The SUPPORT study demonstrated that even for patients with a high probability of dying, it is still difficult for a clinician to predict that a particular patient is about to die. Thus it may be more useful for clinicians to give up relying on their predictive skills, and look at the common clinical paths (or trajectories) taken by dying patients, and design medical care that includes “contingency plans” for clinical problems that a person with incurable lung cancer (for example) is likely to experience. Such contingency plans might include advance directives and perhaps DNAR orders. as well as lines such as: “You will probably die from this, although we can’t predict exactly when. What is really important for you in the time you have left?”

What should I know about the hospice approach?


In order to help someone towards a decent, or even good, death, the hospice framework is very helpful. Hospice started as a grassroots effort, as a view of dying that lets go of the possibility of cure. Instead, hospices emphasize symptom control and attention to psychological and spiritual issues. Pathophysiology becomes less important and personal meaning becomes more important. Thus this framework analyzes a person’s medical care into four major topics, and this can be used to outline day-to-day care plans for a patient:

  1. Pain – one of the things most feared by patients with life-threatening illness.
  2. Symptom control – including dyspnea, nausea, confusion, delirium, skin problems, and oral care.
  3. Psychological issues – especially depression, sadness, anxiety, fear, loneliness.
  4. Spiritual or existential issues – including religious or non-religious beliefs about the nature of existence, the possibility of some type of afterlife.

Hospice care in Washington State is most often provided by multidisciplinary teams who go to patients’ homes. This care is covered by Medicaid for patients judged to have less than six months to live. Hospice care is generally underutilized, and even though most hospice teams feel that at least six weeks of hospice care is optimal, most patients receive much less because they are either referred very late or have not wanted hospice. A major problem in connecting hospice care to acute medical care is that referral implies a “switch” from curative to palliative medicine-a model that does not fit comfortably in many illnesses.

What you need to understand to care for the dying


Another useful framework was outlined by Joanne Lynn, who was one of the principal investigators of SUPPORT. She suggests that there are four things clinicians must know to care for the dying.

  1. The patient’s story – including how that person has viewed her life, the other persons important to her, and how she could bring her life to a close in a way that would be true to herself.
  2. The body – which covers the biomedical understanding of disease, and what limits and possibilities exist for that person.
  3. The medical care system available for this particular patient – knowing how you can make the system work for the patient, as well as the relevant law and ethics.
  4. Finally, you must understand yourself – because you, as a physician, can be an instrument of healing, or an instrument that does damage.

Obviously, learning how to do all this is beyond the scope of this web page–these are goals that guide a career of learning and reflection. But this framework provides guidelines for you as you develop your own approach to caring for dying patients.

How do physicians who care for the dying deal with their own feelings?

It is not hard to find physicians who are burned out – ask any nurse. What is difficult is to find for yourself a type of self-care that will enable you to develop your gifts as a physician, and continue to use them in practice. It helps to learn your strengths and weaknesses, and to actively seek whatever will nurture you – in or out of medicine. A strategy of detachment may not serve you well in the long run. There are indeed rewards for physicians who care for the dying, but as a Zen master once observed of a bingo game, “you must be present to win.”

International Tax Attorneys Washington DC Foreign Acquisitions Joint Ventures Tax Planning: Ivins,

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International Tax

Ivins, Phillips Barker is a recognized national leader in handling U.S. federal income tax issues involving both activities of United States taxpayers in foreign countries, and activities of foreign taxpayers in the United States. Our firm serves individuals and corporations throughout the United States and all over the world.

Our international tax attorneys have mastered all areas of international business taxation, including foreign acquisitions, dispositions and multinational restructurings, joint ventures, tax planning for intangibles, including issues relating to the international licensing of intangibles and international intangible structures, use of hybrid entities, intercompany transfer pricing (including negotiating advance pricing and competent authority agreements), income sourcing, foreign tax credits, allocation and apportionment of deductions, dual consolidated losses, sub part F, income tax treaties, and foreign currency transactions. The lawyers within our international group are involved in analyzing these issues in connection with tax planning transactions and in tax controversies with the Internal Revenue Service.

Our international tax attorneys also regularly advise U.S. and non-U.S. high net worth individuals in connection with U.S. tax issues, including issued relating to business planning for inbound and outbound investment, expatriation, residency and related treaty issues, and participation in the Internal Revenue Service Voluntary Compliance Program, especially in relationship to complying with U.S. foreign bank account reporting rules.

In addition to our talented team of attorneys, we have access to an extensive network of leading firms and practitioners around the world. We are able to call upon the expertise of these colleagues at any time, in order to respond quickly to our clients’ needs. Our clients include United States and foreign multinational corporations.

Representative Experience

  • Structuring multinational corporate structures for publicly traded and private companies, including coordination of tax advice with local counsel
  • Assisting French multinational in connection with reorganization of U.S. corporate structure
  • Advising private textile company in connection with intercompany transfer pricing, including preparation of associated transfer pricing study
  • Representing publicly traded multinational video game company in all aspects of international licensing of intellectual property, including U.S. federal income tax aspects of related income and expense
  • Representing publicly traded multinational entertainment company in competent authority request regarding intercompany royalties.
  • Representing publicly traded multinational company in connection with dual consolidated loss issues relating to its international tax structure
  • Assisting U.S. insurer in connection with planning for offshore structured settlement arrangements
  • Assisting Japanese multinational computer company in negotiating renewal of Advance Pricing Agreement
  • Assisting multinational auto company in connection with audit issues relating to implementation of its Advance Pricing Agreement
  • Representing several individuals in connection with Internal Revenue Service voluntary disclosure program as it relates to disclosure of foreign bank accounts
  • Representing U.S. real estate fund in connection with fund structuring for non-US and tax exempt investors
  • Representing U.S. publicly traded brokerage in connection with U.K. acquisition
  • Representing Europe based broker-dealer in connection with structuring U.S. activities, including transfer pricing aspects
  • Representing U.S. indivdual in connection with “passive foreign investment company” (PFIC) issues in connection with a multi-million dollar disposition of shares of a non-U.S. company
  • Representing non-US person in connection with expatriation issues under Section 877 of the Internal Revenue Code
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Bankruptcy Attorney Orlando #florida #bankruptcy #lawyer,orlando #debt #settlement #attorney,medical #issues,loss #of #job,divorce,bad

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Orlando Bankruptcy and Personal Injury Attorney

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You’re reading this right now because you are considering bankruptcy but you are concerned how it will affect your future or if you will lose your car or house. The truth is most people don’t lose anything but their debt. After filing bankruptcy, you may become debt free. No more calls, no more lawsuits. Suddenly, the worlds feels a bit brighter and filled with possibilities. Filing bankruptcy is not failure. It is a unique financial planning tool that can change your life. But that word bankruptcy. When you think of the word bankruptcy, do you get a sick feeling? It is okay; most people do. No one looks forward to filing bankruptcy. But unfortunately, a great deal of people have no other choice. I know I didn’t. Yes that’s right. I filed bankruptcy before. And guess what? It is not nearly as bad as the word sounds. When your bills have gone unpaid for months and you continue to earn the bare minimum just scraping by, hiring an Orlando bankruptcy lawyer is sometimes the best option. Or maybe you are up to date on paying your bills since you have been withdrawing from your 401K and have finally come to the realization that you just can’t keep up the payments anymore. A great many people think they should enter into a program with a debt settlement company or a credit counseling program before filing bankruptcy. The problem is most times these companies get you into a worse situation than before.

There are others that may be reading this right now that think they are either too young to file bankruptcy or scared to file because they heard they will lose their car or family and friends tell them not to do it. I want to breakdown all the misconceptions and give you the truth during a free consultation with me. I want to share with you my own personal experience with filing bankruptcy and it how it can eliminate your debt, stop harassing debt collector calls and let you sleep at night again. Our Orlando Bankruptcy Attorney Firm helps clients obtain debt relief by filing Chapter 7 or Chapter 13 Bankruptcy and we will continue to help our clients restart their lives.

We understand that most unpaid debts are the result of medical issues, loss of job, divorce or bad luck. Many of our clients even find themselves in a situation where they are being sued by a debt collector; CACH, LLC, Capital One, Chase Bank, Portfolio Recovery. Did you know that if you file bankruptcy, these debts and most judgments against you will most likely be discharged in an Orlando Chapter 7 bankruptcy. You are probably in a situation where you are trying to figure out what to do. You have probably been thinking about filing bankruptcy in Orlando and Kissimmee for quite some time, but you were worried about what you have heard about filing bankruptcy. Stop worrying. Most people recover from a bankruptcy on their credit report within two years.

Bankruptcy Lawyers in Orlando and Kissimmee

The Orlando Bankruptcy Law Firm of Walter F. Benenati, Credit Attorney P.A. has a commitment to aggressive, relentless advocacy on behalf of each client to stop creditor harassment and to help individuals and families get a fresh start. Though as aggressive as we may be in defending your rights, you are not going to see us parading on websites or advertisements looking tough. WE DO NOT HAVE LAWYER EGOS. We understand what our clients are going through. We treat our clients with respect and compassion. That is how we do business. Whether you are the real estate agent that has not sold a property in months, the construction worker trying to put food on the table to feed his family, or the janitor down the street working two jobs, we have devoted our professional careers to helping our clients with their problems and take extreme pride in the results we achieve for them through Chapter 7 or Chapter 13 bankruptcy .

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Call us today at 407-BANKRUPT (407-777-7777) or complete our online form to reset the clock and discuss your need for debt relief in a free office consultation with experienced Orlando, Kissimmee, and Sanford Bankruptcy Attorneys .





The Real Issues of End-of-Life Care #motels #in #santa #barbara

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The Real Issues of End-of-Life Care

The health-care-reform bill the U.S. House of Representatives will debate when it returns from recess next month contains a provision that would have Medicare reimburse doctors for counseling patients on end-of-life care every five years. Opponents of health-care reform have latched onto the provision, claiming it would lead to forced euthanasia or “death panels” to decide whether lifesaving care for the elderly is cost-effective despite the fact that the bill says nothing about either of these frightening issues. In fact, geriatricians doctors trained specifically to care for the elderly support the provision, arguing that it will encourage patients to express their own preferences rather than leave doctors and family members to guess what they want once they’re no longer able to say so themselves. There are only about 7,500 geriatricians in the U.S. and one of them is Dr. Laurie Jacobs, vice chairman of the Department of Medicine at Albert Einstein College of Medicine and Montefiore Medical Center in New York City. Jacobs, who has been a practicing geriatrician since 1988, talked to TIME about why end-of-life counseling is important, when it should start and how to talk to patients and families about planning for death. (Read “If a Health-Care Bill Passes, Nurse Practitioners Could Be Key.”)

Does this House provision for funding end-of-life counseling concern you?
This provision says that people should talk about what their goals of care are and what they want at the end of life. That could be anything. This is an opportunity for patients and physicians to share information with each other and come up with a plan. It is one of the special things about being a physician. You get to know your patient and what matters to them, and their inner thoughts, and their lives, and that’s a very special role that most physicians value and that patients appreciate.

How important is Medicare reimbursement for doctors counseling patients about end-of-life care?
For some people one conversation is enough, and you get the whole picture and they tell you exactly what they want. For other people, 10 conversations in 10 weeks won’t suffice. Coverage for this is expensive, but I think offering it is a wonderful first step in highlighting the importance of it by paying for it.

What kind of end-of-life-care counseling do you provide to your patients? How does it work?
Many patients have chronic illness and some disability or medical issue, and part of providing care is to speak with them about what to expect with their illness, what alternatives exist, and to have a conversation about what their preferences are. This shouldn’t just happen at the end of life. You should get to know people and have these conversations throughout providing care. I like to talk individually with the patient if they are comfortable with that. If they are more comfortable with having family members there at the time, then I do it with the group. What I need to know from the patients is how they view their illness in the context of their life. Did they know somebody else with the same condition and therefore they have some preconceived idea about this? What are their values? How to they want to live their life? I also talk to them about whether there is someone who could make decisions for them if they are unable in the future.

How often do you provide end-of-life counseling?
It comes up very frequently in our practice, either with new patients who present very ill, or patients we have known for a very long time that have encountered a new serious condition that may be life-threatening. Death is not an option. Everyone is going to die at some point.

How important is for you to talk with people about options like hospice or do-not-resuscitate orders? This must be really stressful for patients and their families.
That’s why it’s so important to talk about values and preferences long before you are at the moment of having to do an intervention. If I have a patient who has early dementia, they still may be able to participate in a conversation about what matters to them, how they want to live their life, who they want to make decisions, and it may be 10 years before the point at which an illness happens and an intervention may be required. So, it enables me to get a sense of who they are and what’s important to them. When you talk to family members when a patient cannot participate in the conversation, it’s even more difficult. If it was for themselves, they might say, “Gee, I don’t want to go through that,” but they are afraid to limit options for family members, and I can understand that. If a proxy knows that the patient always said, “This is how I want to live my life, this is how I want my life to end,” they feel very much more comfortable in making those decisions. So I think the fact that there is some national conversation about this is good in that it starts people talking to their friends and family about what is important to them.

How often does money come up with families or patients when you are talking about end-of-life care?
This is a question that medical students often ask. Health-care finance and social issues regarding health-care expenditures nationally are policy issues, and they are never to be decided at the bedside.

Christian Life Resources – End of Life Issues #motel #clothing #uk

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End of Life Issues

Featured Article:
Look at What is Coming

In 2011 Mariette Buntjens was a patient suffering from metastatic cancer at a Roman Catholic nursing home in Diest, Belgium. Buntjens requested euthanasia but the nursing home refused on obvious religious grounds. Her family brought her home where she said her good-byes and she was then given a lethal cocktail of drugs to end her life. In January of this year her daughter filed a lawsuit against the nursing home for failing to permit the killing at the facility.

Earlier this month a judgment was reached. The nursing home was ordered to pay 1,000 euros (about $1,100) to each of the three children and 3,000 euros as a fine for failing to permit the killing.

Since the earliest efforts to legalize euthanasia in America we have expressed concern that Christians will be forced to participate in these killings. Advocates for the legalization of assisted suicide have dismissed those concerns as exaggerations. Really?

Take a look just in America at what has been happening with the binding of religious consciences for pharmacists and some forms of birth control or businesses and medical professionals and the performance of abortions, and participation in gay marriages.

Despite the surface logic for autonomy we must realize that the tentacles that permit sin run deep and are pervasive. It is simplistic to think a my body, my choice mentality stops there.

Society is in full rebellion against the Biblical truth that some things are wrong, or in religious parlance, sin. In a post-modern society nobody likes to talk about right and wrong but muting the reality does not change the reality. Surrendering to some sin surrenders to sin s ultimate agenda total rebellion against God. It is a slippery slope, indeed.

More End of Life Issues Articles

Look at What is Coming
In 2011 Mariette Buntjens was a patient suffering from metastatic cancer at a Roman Catholic nursing home in Diest, Belgium. Buntjens requested euthanasia but the nursing home refused. July 27th, 2016

Q Position Statement on Abortion: Click Here Christian Life Resources Position Statement on Euthanasia: Click Here June 26th, 2014

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UKCEN: Ethical Issues -End of Life Decisions #low #price #hotels

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Ethical Issues – End of life decisions

Ethical Considerations

A number of ethical theories and principles are relevant when considering treatment decisions at the end of life.

Sanctity of Life Doctrine

The argument underpinning this doctrine is that all human life has worth and therefore it is wrong to take steps to end a person s life, directly or indirectly, no matter what the quality of that life. This is in keeping with both traditional codes of medical ethics and a general perception of what doctors and other health professionals should do, that is save and preserve life. One challenge to this principle in the context of health care is to ask should life be preserved at all costs. Is there no place for consideration of quality of life? One of the problems with considering quality of life is the question of how this is defined and by whom. An objective view of someone s life may be very different to the view of the person who is living that life. However, this problem does not remove the challenge to the sanctity of life doctrine. There may be some circumstances where a person s quality of life, however defined, is so poor that it should not be maintained even if it is possible to do so. Some ethical arguments have been developed to address this challenge.

Acts /omissions distinction

This distinction argues that there is a difference between actively killing someone and refraining from an action that may save or preserve that person s life. Thus it is morally wrong to push someone into a river to their death but we may not have a moral duty to leap into the river to save someone who is drowning. In a medical context this distinction would mean that a doctor could not give a patient a lethal injection to end his/her life, whatever the circumstances, but could, withhold treatment that may sustain it. Withholding treatment would only be permissible if the patient s quality of life was so poor, and the burden of treatment so great, that it would not to be in the patient s best interests to continue treatment. For example, it might be permissible not to ventilate a patient if he/she was in chronic respiratory failure, or not to use tube feeding if he/she was in a permanent vegetative state.

Doctrine of Double Effect

The doctrine of double effect argues that there is a moral distinction between acting with the intention to bring about a person s death and performing an act where death is a foreseen but unintended consequence.

The doctrine of double effect allows that performing an act that brings about a good consequence may be morally right even though the good consequence can only be achieved at the risk of a harmful side effect. Prescribing pain relieving drugs which in large doses shorten the life of a terminally ill patient is often used as an example of double effect. The intention is to relieve pain and the foreseen but unintended consequence is that the patient’s life will be shortened. Current practice in palliative medicine and the range of drugs available may reduce the appropriateness of this doctrine.

Respect for autonomy

The principle for respect for autonomy acknowledges the right of a patient to have control over his or her own life, including decisions about how his/her life should end. Thus a competent person should be able to refuse life saving treatment in both current situations and future foreseeable situations. Should respect for autonomy mean that a person can request assistance in ending his/her life? Some would argue that this is the case but as assisted suicide is currently illegal in the UK this is not an issue that a clinical ethics committee should need to consider. Does respect for autonomy mean that a patient can request treatment that the clinician does not think is in his/her best interests, or treatment that is futile? In these situations the principle of respect for autonomy comes into conflict with other ethical considerations, such as preventing or avoiding harm, or distributive justice.

A duty to act in the patient s best interest (Beneficence)

The duty of beneficence, that is to act in a way that benefits the patient, is an important ethical principle in health care. In treatment decisions at the end of life the dilemma often revolves around what course of action will be in the patient’s best interests. It is difficult to see how death can be a benefit or in the patient’s interests, but in some circumstances, if existing quality of life is so poor, or treatment is very burdensome, then the balance of harms and benefits may suggest that continuing treatment is not a benefit to the patient.

A duty not to harm (Nonmaleficence)

The concept of nonmaleficence – an obligation not to inflict harm intentionally, is distinct from that of beneficence – an obligation to help others. In codes of medical practice the principle of nonmaleficence (primum non nocere) has been a fundamental tenet. However, in the context of health care it can sometimes be difficult to comply with this principle depending on the definition of harm. Many medical treatments may have harmful side effects but save or improve lives. In end of life decisions the question of how much harm is caused by the treatment needs to be considered, as does the question of whether death itself is always a harm.

Page created: May 26, 2011

End-of-Life Decisions – End of Life Issues – California Medical Association #roach

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End-of-Life Decisions

California law provides individuals the ability to ensure that their health care wishes are known and considered if they become unable to make these decisions themselves.

The California Medical Association (CMA) encourages Californians to think and talk with loved ones about their wishes for end-of-life medical care before a serious illness or injury occurs. CMA has developed a number of guidelines, forms, and other resources to assist providers, patients, and loved ones with making important end-of-life decisions.

NEW! California s End Of Life Option Act

On October 5, 2015, California became the fifth state in the nation to allow physicians to prescribe terminally ill patients medication to end their lives. ABX2-15, the “End of Life Option Act,” permits terminally ill adult patients with capacity to make medical decisions to be prescribed an aid-in-dying medication if certain conditions are met. The following document discusses the requirements under the End of Life Option Act, which went into effect June 9, 2016:

  • CMA On-Call #3459: The California End of Life Option Act
  • On-demand webinar: The California End of Life Option Act: An Overview

Advance Health Care Directive

In California, advance directives are the legally recognized format for living wills. An advance directive enables individuals to make sure that their health care wishes are known in advance and considered if for any reason they are unable to speak for themselves. Advance directives also allow patients to appoint a health care “agent” who will have legal authority to make health care decisions in the event that the patient is incapacitated, or immediately upon appointment if the patient expressly grants such authority.

See below for more information about advance directives, or to purchase CMA’s Advance Health Care Directive Toolkit, available in English and Spanish:

  • CMA Advance Health Care Directive Kit in English (rev. 3/14)
  • CMA Advance Health Care Directive Kit in Spanish (rev. 9/14)
  • CMA On-Call #3451. Decisions Regarding Life-Sustaining Treatment – Advance Directives and POLST (2015)
  • CMA On-Call #3450. Decisions Regarding Life-Sustaining Treatment for Patients Without Advance Directive or POLST (2015)

Physician Orders for Life-Sustaining Treatment

Physician Orders for Life Sustaining Treatment (POLST) in 2009 became a legally recognized document, similar to the widely used do not resuscitate (DNR) orders. The POLST form, used for patients with a serious illness or whose life expectancy is a year or less, outlines a plan of care reflecting the patient s wishes concerning medical treatment and interventions at life s end. The POLST form complements an advance directive by turning a patient s treatment preferences into actionable medical orders.

See below for more information about POLST, or to purchase CMA’s POLST toolkit, available in English and Spanish:

  • 2016 POLST form (effective January 1, 2016)
  • CMA POLST Kit in English (rev. 12/15)
  • CMA POLST Kit in Spanish (rev. 10/14)
  • CMA On-Call #3451. Decisions Regarding Life-Sustaining Treatment – Advance Directives and POLST (2015)
  • CMA On-Call #3450. Decisions Regarding Life-Sustaining Treatment for Patients Without Advance Directive or POLST (2015)

Do Not Resuscitate (DNR) Form

The Pre-Hospital DNR form, developed by the California Emergency Medical Services in conjunction with the California Medical Association, instructs EMS personnel to forgo resuscitation attempts in the event of a patient’s cardiopulmonary arrest. Below you will find CMA resources that include additional details about DNR requests and purchasing information for the DNR form in English and Spanish.

  • Do Not Resuscitate Form in English
  • Do Not Resuscitate Form in Spanish
  • CMA On-Call #3453. Decisions Regarding Resuscitative Measures DNR Requests Orders and Cardiopulmonary Resuscitation (2015)

Other Resources

CMA’s Health Law Library
Updated annually, CMA’s online health law library contains nearly 5000 pages of valuable information for physicians and their staff. The CMA Center for Legal Affairs has developed several On-Call documents on important end-of-life issues in the medical practice. Access to the library is FREE to members. Nonmembers can purchase documents for $2 per page.

  • On-Call #3452. Documenting Decisions Regarding Life-Sustaining Treatment
  • On-Call #3454. Decisions Regarding Life-Sustaining Treatment and the Patient Self-Determination Act and Joint Commission
  • On-Call #3455. Physician-Assisted Suicide
  • On-Call #3456. Responding to Request for Non-Beneficial Treatment
  • On-Call #3458. CMA Model Policy: Responding to Requests for Non-Beneficial Treatment
  • On-Call #3400. Autopsies
  • On-Call #3401. Organ and Tissue Donation
  • On-Call #3402. Pronouncement of Death and Death Certificates
  • On-Call #3403. Pronouncement of Death Diagnosis of Death by Neurologic Criteria

For Patients
For more information about end-of-life medical decisions, visit the Coalition for Compassionate Care of California (CCCC) website, www.coalitionccc.org.

The booklet Finding Your Way was written by the Center for Healthcare Decisions as a useful guide to thinking about and discussing end-of-life issues. To order a copy, visit the CCCC website or call the organization at (916) 489-2222.

If you have a serious medical condition or have been diagnosed with a terminal illness, CMA encourages you to talk to your doctor about POLST. Before initiating that conversation, you may wish to visit www.capolst.org or the California Coalition for Compassionate Care website for more information.

For Providers
End-of-life resources for health care providers are available at the Coalition for Compassionate Care of California website. CCCC also provides decision guides. palliative care tools and resources for physicians.

End-of-Life Issues: Ethical Topic in Medicine #motel #stari #hrast

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End-of-Life Issues

A s care of the dying involves so much of one’s self, in this topic page I will describe my approach as an one example of how clinicians think about end-of-life care. I remember, the first time one of my patients died, feeling a chill of horror and fascination. I wasn’t prepared for it. The resident yawned–a long night, then a long code. “We better go talk to the family.” What in the world would we say? The dead patient, now dusky blue, looked unreal and unfamiliar. I was so wrapped up in my own feelings that I can’t recall much else.

Now I find care of the dying to be one of the richest parts of my clinical life. But it is demanding in a different, more personal way, than, say, treating pneumococcal pneumonia with penicillin. Here I will describe some ways of thinking about care of the dying that have helped me figure out where I am going as I guide someone who is really sick.

Many medical students first encounter care of the dying as an unsuccessful code or a strategic withholding of CPR. Of course, an ethically sound understanding of withdrawing and withholding treatment is crucial to good care of the dying. Yet “withholding and withdrawing” only describe what we, as clinicians, decide not to do. To provide excellent care of the dying requires that we also decide what we should do. What should be the goals of medical care for people who are dying? What makes a good death?

What is a “good death”? A medical perspective

The good death is not a familiar idea in American culture. Some experts in palliative care describe the United States as a “death-defying” culture, with a mass media that spotlights only youth and beauty. Yet public interest in care of the dying is currently high. The striking public interest in physician aid-in-dying is one obvious reason. But there are other reasons: over the past 100 years, there has been a epidemiologic shift in the reasons people die. In the pre-antibiotic era, people most often died young, of infectious diseases; now, thanks to medical technology, most Americans (and others with access to this technology) live much longer, to die of degenerative, neoplastic, and even man-made diseases. Finally, there is a marked public fear that a medical death, depicted in TV shows like “ER” as an unresponsive, uncommunicative body hooked up to an array of flashing monitors, represents an irresponsible use of technology and a dishonorable way to treat a person.

Interestingly, contemporary medical literature contains little that might characterize what makes a death “good.” Recently, a large, expensive empirical study of intensive care unit deaths suggested that medical care for a common type of in-hospital death is “bad” (the SUPPORT study, referenced below). In this study of dying patients, severe pain was common, decisions to withhold invasive treatments were made at the last minute, and physicians often had no knowledge of patient preferences not to have CPR. Even worse, an intervention designed to provide physicians with better prognostic information had no effect on medical decision making prior to death. While the SUPPORT authors did not actually describe these deaths as “bad,” we could certainly agree that they were not “good deaths.”

In caring for a person who is dying, knowing what would make the experience of dying “good” is an important goal for physicians and other members of the care team. I find it doesn’t take fancy techniques-you just need to be sincere and patient and interested. Listen more and talk less. Try asking something like, “Knowing that all of us have to think about dying at some point, what would be a good death for you?” What people choose when they think about a good death for themselves is often beyond what medicine can provide-for instance, an affirmation of love, a completion of important work, or a last visit with an important person. As a physician, I can’t always make those things happen. But I can help the dying person get ready-and in this way, contribute to a death that is decent.

What goals should I have in mind when working towards a decent death for my patient?


I have several working clinical goals when I am caring for someone near the end of life. I work towards:

  1. Control of pain and other physical symptoms. The physical aspects of care are a prerequisite for everything that follows.
  2. Involvement of people important to the patient. Death is not usually an individual experience; it occurs within a social context of family, significant others, friends, and caregivers.
  3. A degree of acceptance by the patient. Acceptance doesn’t mean that the patient likes what is going on, and it doesn’t mean that a patient has no hopes–it just means that he can be realistic about the situation.
  4. A medical understanding of the patient’s disease. Most patients, families, and caregivers come to physicians in order to learn something about what is happening medically, and it is important to recognize their need for information.
  5. A process of care that guides patient understanding and decision making. One great physician does not equal great care–it takes a coordinated system of providers.

How do you know when someone is dying?

This question is not as simple as it might sound. The SUPPORT study demonstrated that even for patients with a high probability of dying, it is still difficult for a clinician to predict that a particular patient is about to die. Thus it may be more useful for clinicians to give up relying on their predictive skills, and look at the common clinical paths (or trajectories) taken by dying patients, and design medical care that includes “contingency plans” for clinical problems that a person with incurable lung cancer (for example) is likely to experience. Such contingency plans might include advance directives and perhaps DNAR orders. as well as lines such as: “You will probably die from this, although we can’t predict exactly when. What is really important for you in the time you have left?”

What should I know about the hospice approach?


In order to help someone towards a decent, or even good, death, the hospice framework is very helpful. Hospice started as a grassroots effort, as a view of dying that lets go of the possibility of cure. Instead, hospices emphasize symptom control and attention to psychological and spiritual issues. Pathophysiology becomes less important and personal meaning becomes more important. Thus this framework analyzes a person’s medical care into four major topics, and this can be used to outline day-to-day care plans for a patient:

  1. Pain – one of the things most feared by patients with life-threatening illness.
  2. Symptom control – including dyspnea, nausea, confusion, delirium, skin problems, and oral care.
  3. Psychological issues – especially depression, sadness, anxiety, fear, loneliness.
  4. Spiritual or existential issues – including religious or non-religious beliefs about the nature of existence, the possibility of some type of afterlife.

Hospice care in Washington State is most often provided by multidisciplinary teams who go to patients’ homes. This care is covered by Medicaid for patients judged to have less than six months to live. Hospice care is generally underutilized, and even though most hospice teams feel that at least six weeks of hospice care is optimal, most patients receive much less because they are either referred very late or have not wanted hospice. A major problem in connecting hospice care to acute medical care is that referral implies a “switch” from curative to palliative medicine-a model that does not fit comfortably in many illnesses.

What you need to understand to care for the dying


Another useful framework was outlined by Joanne Lynn, who was one of the principal investigators of SUPPORT. She suggests that there are four things clinicians must know to care for the dying.

  1. The patient’s story – including how that person has viewed her life, the other persons important to her, and how she could bring her life to a close in a way that would be true to herself.
  2. The body – which covers the biomedical understanding of disease, and what limits and possibilities exist for that person.
  3. The medical care system available for this particular patient – knowing how you can make the system work for the patient, as well as the relevant law and ethics.
  4. Finally, you must understand yourself – because you, as a physician, can be an instrument of healing, or an instrument that does damage.

Obviously, learning how to do all this is beyond the scope of this web page–these are goals that guide a career of learning and reflection. But this framework provides guidelines for you as you develop your own approach to caring for dying patients.

How do physicians who care for the dying deal with their own feelings?

It is not hard to find physicians who are burned out – ask any nurse. What is difficult is to find for yourself a type of self-care that will enable you to develop your gifts as a physician, and continue to use them in practice. It helps to learn your strengths and weaknesses, and to actively seek whatever will nurture you – in or out of medicine. A strategy of detachment may not serve you well in the long run. There are indeed rewards for physicians who care for the dying, but as a Zen master once observed of a bingo game, “you must be present to win.”

End-of-Life Decisions – End of Life Issues – California Medical Association #stages

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End-of-Life Decisions

California law provides individuals the ability to ensure that their health care wishes are known and considered if they become unable to make these decisions themselves.

The California Medical Association (CMA) encourages Californians to think and talk with loved ones about their wishes for end-of-life medical care before a serious illness or injury occurs. CMA has developed a number of guidelines, forms, and other resources to assist providers, patients, and loved ones with making important end-of-life decisions.

NEW! California s End Of Life Option Act

On October 5, 2015, California became the fifth state in the nation to allow physicians to prescribe terminally ill patients medication to end their lives. ABX2-15, the “End of Life Option Act,” permits terminally ill adult patients with capacity to make medical decisions to be prescribed an aid-in-dying medication if certain conditions are met. The following document discusses the requirements under the End of Life Option Act, which went into effect June 9, 2016:

  • CMA On-Call #3459: The California End of Life Option Act
  • On-demand webinar: The California End of Life Option Act: An Overview

Advance Health Care Directive

In California, advance directives are the legally recognized format for living wills. An advance directive enables individuals to make sure that their health care wishes are known in advance and considered if for any reason they are unable to speak for themselves. Advance directives also allow patients to appoint a health care “agent” who will have legal authority to make health care decisions in the event that the patient is incapacitated, or immediately upon appointment if the patient expressly grants such authority.

See below for more information about advance directives, or to purchase CMA’s Advance Health Care Directive Toolkit, available in English and Spanish:

  • CMA Advance Health Care Directive Kit in English (rev. 3/14)
  • CMA Advance Health Care Directive Kit in Spanish (rev. 9/14)
  • CMA On-Call #3451. Decisions Regarding Life-Sustaining Treatment – Advance Directives and POLST (2015)
  • CMA On-Call #3450. Decisions Regarding Life-Sustaining Treatment for Patients Without Advance Directive or POLST (2015)

Physician Orders for Life-Sustaining Treatment

Physician Orders for Life Sustaining Treatment (POLST) in 2009 became a legally recognized document, similar to the widely used do not resuscitate (DNR) orders. The POLST form, used for patients with a serious illness or whose life expectancy is a year or less, outlines a plan of care reflecting the patient s wishes concerning medical treatment and interventions at life s end. The POLST form complements an advance directive by turning a patient s treatment preferences into actionable medical orders.

See below for more information about POLST, or to purchase CMA’s POLST toolkit, available in English and Spanish:

  • 2016 POLST form (effective January 1, 2016)
  • CMA POLST Kit in English (rev. 12/15)
  • CMA POLST Kit in Spanish (rev. 10/14)
  • CMA On-Call #3451. Decisions Regarding Life-Sustaining Treatment – Advance Directives and POLST (2015)
  • CMA On-Call #3450. Decisions Regarding Life-Sustaining Treatment for Patients Without Advance Directive or POLST (2015)

Do Not Resuscitate (DNR) Form

The Pre-Hospital DNR form, developed by the California Emergency Medical Services in conjunction with the California Medical Association, instructs EMS personnel to forgo resuscitation attempts in the event of a patient’s cardiopulmonary arrest. Below you will find CMA resources that include additional details about DNR requests and purchasing information for the DNR form in English and Spanish.

  • Do Not Resuscitate Form in English
  • Do Not Resuscitate Form in Spanish
  • CMA On-Call #3453. Decisions Regarding Resuscitative Measures DNR Requests Orders and Cardiopulmonary Resuscitation (2015)

Other Resources

CMA’s Health Law Library
Updated annually, CMA’s online health law library contains nearly 5000 pages of valuable information for physicians and their staff. The CMA Center for Legal Affairs has developed several On-Call documents on important end-of-life issues in the medical practice. Access to the library is FREE to members. Nonmembers can purchase documents for $2 per page.

  • On-Call #3452. Documenting Decisions Regarding Life-Sustaining Treatment
  • On-Call #3454. Decisions Regarding Life-Sustaining Treatment and the Patient Self-Determination Act and Joint Commission
  • On-Call #3455. Physician-Assisted Suicide
  • On-Call #3456. Responding to Request for Non-Beneficial Treatment
  • On-Call #3458. CMA Model Policy: Responding to Requests for Non-Beneficial Treatment
  • On-Call #3400. Autopsies
  • On-Call #3401. Organ and Tissue Donation
  • On-Call #3402. Pronouncement of Death and Death Certificates
  • On-Call #3403. Pronouncement of Death Diagnosis of Death by Neurologic Criteria

For Patients
For more information about end-of-life medical decisions, visit the Coalition for Compassionate Care of California (CCCC) website, www.coalitionccc.org.

The booklet Finding Your Way was written by the Center for Healthcare Decisions as a useful guide to thinking about and discussing end-of-life issues. To order a copy, visit the CCCC website or call the organization at (916) 489-2222.

If you have a serious medical condition or have been diagnosed with a terminal illness, CMA encourages you to talk to your doctor about POLST. Before initiating that conversation, you may wish to visit www.capolst.org or the California Coalition for Compassionate Care website for more information.

For Providers
End-of-life resources for health care providers are available at the Coalition for Compassionate Care of California website. CCCC also provides decision guides. palliative care tools and resources for physicians.