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

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