NAELA PUBLIC POLICY GUIDELINES

HEALTH CARE DECISION-MAKING


A. Advance Planning

1. Good health care decision-making requires a meaningful, ongoing process of communication among patient, family and health care provider regarding present and future health care decisions, shaped primarily by the patient's needs, values and goals for how the individual wishes to live throughout life and as life's end approaches.

2. Advance directive statutes provide a very good but nonexclusive pathway for expressing wishes and preferences for medical treatment, including end-of-life care. Constitutional and common law, as well as medical ethical principles require respect for any other authentic expression of one's wishes regarding care and treatment.

3. Advance Planning should emphasize the appointment of a health care decision maker and involvement of that decision maker in advance planning discussions. It should also include a realistic discussion of possible provider or family opposition to health care choices chosen by the patient, and consider ways to address such objections in advance. The designated decision maker should be prepared to serve as confidante, advocate and spokesperson for the patient during difficult circumstances.

4. The public needs a variety of advance planning tools, since no two people approach the task in exactly the same way, and no one form or planning tool is ideal for everyone.

5. Cultural and ethnic diversity among Americans will result in differing views on health care treatment and the decision making process and such differences should be respected under the law and by all providers.

6. Statutory advance directive rules require simple, flexible, user-friendly and meaningful interpretation and implementation, so that the process is tailored to meet the individual's needs as well as personal and cultural preferences.

7. The public should have access to the benefits of an ethics committee or other conflict resolution options as well as information about the basic elements of good end-of-life care.

8. Individuals should be encouraged to review their directives at any time there is a significant health change status, or at least every five years, and to renew discussions about their wishes with family and friends at that time.

9. Dying should be understood as a natural occurrence, inevitable and capable of being anticipated in an accepting manner. There are limits to the availability and efficacy of medical treatment and serious questions about allocation of resources that must be acknowledged.

Based on these principles, NAELA recommends that states:

1. Affirm the right of competent individuals to make their own health care decisions and to direct the process and content of health care decisions during times of incapacity through advance directives. Write and review laws relating to advance directives in a manner which allows individuals to actuate their individual choices.

2. Adopt a single, comprehensive and simple health care decision-making statute that permits written or oral advance directives, and consider adopting the Uniform Act regarding advance directives.

3. Avoid mandatory forms or language for advance directives.

4. Avoid imposing special conditions or evidentiary requirements upon the withholding or withdrawal of life-sustaining treatments and/or artificial nutrition and hydration.

5. For patients who do not name a person to act on their behalf, authorize default decision makers to make health care decisions, including decisions about life support and life prolonging treatment.

6. Make "close friends" permissible default decision makers.

7. Recognize out-of-state advance directives as presumptively valid and enforceable absent good cause.

8. Provide support for difficult decision-making cases by requiring all health care facilities to have access to ethics committees available to patients, families, and providers for consultation, education, and policy development.

9. Educate the public about end-of-life treatments and the relative economic and societal costs involved.

Pain and Palliative Care Policy

NAELA supports laws, policies, and guidelines that optimally balance the need for ready access to drugs and other interventions for relief and cure with the need to prevent drug diversion and abuse. NAELA supports the following criteria developed by the Pain and Policy Studies Group of the University of Wisconsin School of Medicine and Public Health to identify provisions that enhance pain management:

1. Controlled substances are recognized as necessary for public
health;

2. Pain management is recognized as part of general medical practice

3. Medical use of opioids is recognized as legitimate professional practice

4. Pain management is encouraged

5. Practitioners' concerns about regulatory scrutiny are addressed;

- Prescription amount alone is recognized as insufficient to determine legitimacy of prescribing;

- Physical dependence or analgesic tolerance are not confused with "addiction."

NAELA recognizes the following criteria developed by the Pain and Policy Studies Group of the University of Wisconsin School of Medicine and Public Health that identify provisions that impede pain management and should be discouraged:

1. Opioids are considered a treatment of last resort

2. Medical use of opioids is implied to be outside legitimate professional practice;

3. Physical dependence or analgesic tolerance are confused with "addiction";

4. Medical decisions are restricted, by patient characteristics, or mandated consultation, or by caps on quantity prescribed or dispensed, or other undue prescription limitations;

5. Length of prescription validity is restricted;

6. Practitioners are subject to undue prescription requirements;

7. Other provisions that may impede pain management;

8. Provisions are ambiguous, because of arbitrary standards for legitimate prescribing, unclear intent leading to possible misinterpretation, or conflicting or inconsistent policies or provisions.

NAELA supports laws and policies that offer all Americans when they are dying:

1. Comprehensive services that meet their individual needs medical, emotional, social, and spiritual;

2. Health plans and programs such as hospice care that cover such care, and;

3. Health care providers well trained in palliative care.


Resolutions adopted by the NAELA Board of Directors November 17, 1991
Revised May 6, 1998 and June 29, 2007
Posted March 2013