Where Do We Go From Here?

From a legal perspective, an advance directive document would've given the son some "teeth" in terms of support for the decision to die at home. He and the health care providers wouldn't have had to rely on "substituted judgement". However, advance directive or not, there was a lack of knowledge among the coroner, sheriff, and district attorney about end of life processes. In my opinion, there is leeway for the sheriff and district attorney for lack of knowledge of end of life processes, but not the coroner who is a MD. The literature is still referring to continuing need for education in this area. I was frustrated in this case to find that these people did not seek medical advice or opinions until the defense attorney provided it to them in the form of my meeting with them and a letter from Dr. Barbara Daly. Why didn't they seek counsel? Why did they wait four years to indite the family? Were there politically motivating influences?

Why wasn't education provided to the family by the physician, nurse practitioner, or home care agency? Why wasn't a hospice referral made? Was there a knowledge deficit because it was rural, small town versus bigger city teaching hospital ? The photographs not soon after the death would be alarming to a non medical person. Yes, her physical condition at death would've probably been better had she been in a hospice program, but this family did nor receive the needed support or direction from their health care providers. They did not "know what they did not know". They did the best that they knew how.

Nursing and medical school curriculum need more content in the dying process: physiology and comfort measures. It is not just the job of hospice to provide that education and support to patients and families. Not every patient chooses hospice and that makes it important that all health care providers have the knowledge. We also need to teach more depth in advance directives and not solely at the knowledge level of content. The inclusion of affective learning objectives through case study and reflection would add a lasting dimension to the content.

Lastly, what can the legal nurse consultant do to facilitate learning for the legal profession? Educational programs can be provided at bar association meetings, to coroners, and to the courts to increase knowledge so that another family would never have to incur the expenses or emotional trauma that this case inflicted.