The U.S. Supreme Court recognized the constitutional right of self-determination concerning refusing life-sustaining medical treatment (Cruzan v. Commissioner, Missouri Department of Health, 497 US 261, 1990). The decision required the hospital to honor the family's demand to remove life support from Nancy Cruzan. Nancy Cruzan was a victim of an automobile accident and had languished in an irreversible coma for nine years.
On December 1, 1991, the U.S. Congressional Patient Self-determination Act (PSDA) took effect. The PSDA requires Medicare and Medicaid providers (such as hospitals, nursing homes, hospices, home health agencies, and HMOs) to give adults information about their rights under state laws at the time of admission. The report includes the patient's rights regarding advance directives and the right to accept or refuse medical or surgical treatment.
The act also prohibits an institution from discriminating against a patient who does not have or want an advance directive. If the patient is a minor or is incapacitated, these rights extend to the patient's representative. The decisions that patients, or their representatives, make may not always coincide with healthcare providers' advice, but those decisions need to be respected.
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Patients have the right to self-determination and to make decisions about treatment and course of care.
Palliative care patients also have the right to determine where they want to be living and maybe subsequently dying. The place where Americans die is influenced by factors, including individual preference, cultural beliefs, access to care, age, cause of death, social support, race, ethnicity, health insurance coverage, and services used around the time of death.
As our population ages, chronic incapacitating disease and pain management along with end-of-life care have created important quality of life issues. Besides, intensive care science can regularly sustain physiologic activity for extended periods even after brain death. To acknowledge the patient's right to self-determination even in the event of incapacitation, every state has devised some form of advanced directive. Advance directives are legally recognized orders that give voice to a patients' health care preferences if they cannot communicate.
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