Treatment at the end of life. A legal and ethical standpoint

Palliative care in its narrower sense is characterized by a change in the goals of medical treatment, i.e. sustaining life is no longer the primary objective while alleviating suffering is identified as the exclusive intention. Medical indications precede patient's consent. However, to establish legitimacy consent has to be obtained in all cases. For patients no longer competent to decide, advance directives may be helpful in the decision-making process. According to a new law in Germany these documents have to be interpreted by physicians together with patients' surrogates and are legally binding only if the content is sufficiently concrete. As an alternative concept advanced care planning has been established in palliative care to improve patients' autonomy. Active euthanasia contradicts professional ethics and is prohibited by German law. The intention to shorten life may be ethically well distinguished from morally justified acts of stopping or forgoing life-sustaining treatment by using recently elaborated concepts and terminology in medical ethics. In addition this holds true for decisions about limiting nutrition and hydration at the end of life. Decisions have to be based on careful examination of all relevant medical and ethical aspects in each individual case.