Most people assume that they, their family or those who know them best will make decisions affecting how they die. In fact, state and federal laws govern some of the most central issues related to end-of-life care and decision-making. In order to be sure that one's own preferences for end-of-life care are followed it is necessary to understand these laws.

• A competent person (a person who is able to make decisions) has a constitutional right to be free of unwanted medical treatment even if death is the result. For patients who can no longer communicate decisions, all 50 states have established procedures for how decisions will be made. Advance directives are common tools for this purpose.
• Advance directives (including living wills, medical powers of attorney, and health care proxies) are legal documents that enable people to give instructions about future medical care and to appoint another person to make health care decisions if they are unable to make these decisions. Each state has laws recognizing the use of advance directives and regulates them differently.
• The Patient Self-Determination Act is a federal law that requires health care facilities to inform patients of their right to prepare advance directives.
• A Do-Not-Resuscitate (DNR) order is different from living wills and medical powers of attorney in that the patient or the health care agent cannot prepare it. It is a written order that is signed by a physician and it instructs other health care providers not to attempt cardiopulmonary resuscitation (CPR) in the case of cardiac or respiratory arrest. The Joint Commission on Accreditation of Health Care Organizations requires that every facility have a policy regarding the use of do-not-resuscitate (DNR) orders.
• Advance directives are not followed in emergencies, such as when 911 is called. However, many states now have laws that permit a “Non-Hospital DNR Order,” an order signed by a physician that can be honored by emergency medical personnel. A DNR order is not a “do-not-treat” order, and EMS will provide other necessary treatment.
• Advance directives are most commonly used to give instructions about if or when life-support treatments should be withheld or withdrawn. However, they can be used to express other wishes as well, such as a request for pain management, a preference to die at home if possible, or preferences regarding organ donation.
• Sometimes there is confusion as to whether or not artificial nutrition and hydration can be withheld or withdrawn. Artificial nutrition and hydration (tube feeding) is a medical treatment and a form of life support. However, when the patient cannot communicate, some state laws require more evidence of the patient's wishes regarding tube feeding than do others.
• Physician assisted suicide occurs when a physician knowingly and intentionally provides the means (usually a prescription for a lethal dose of drugs) that a competent, terminally ill patient may take to end his or her life. At this time this practice is legal only in the state of Oregon under a very narrow set of conditions.
• Euthanasia, commonly called mercy killing, is not legal in any state. This occurs when someone directly causes the death of a person (for example, by giving a lethal injection) to relieve suffering.
• Giving drugs for pain management that have the rare and unintended consequence of shortening a person's life is not euthanasia or assisted suicide.
• Withholding or withdrawing unwanted medical treatment is not euthanasia or assisted suicide. However, if the patient can no longer make decisions, state laws can affect how these decisions are made.
• Brain death refers to the irreversible loss of all brain function, and most states legally define death to include brain death. A person in a persistent vegetative state or other circumstances in which there is not a loss of all brain function is not “brain dead,” so is not legally dead, and life-support treatments may be continued.

Editor's Note: This article was originally published on www.lastacts.org, the Web site for Last Acts, formerly a national program of the Robert Wood Johnson Foundation. Be advised that the content of this article might be dated or inaccurate. The Foundation is reprinting the article here as a matter of general and historical interest.