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Missouri’s Death-Prolonging Procedures Act of 1985 represents an effort to ensure that an individual’s choices regarding medical treatment will be honored, even if the individual becomes incompetent. This article considers the Act’s limiting structure and examines the effect of these limits on the effectiveness of the Act in providing a legal right to refuse medical treatment.

Following an introduction, Part II describes the limiting structure of the Act. Part III considers the way in which the Act’s limitations relate to its binding effect.

First, an individual’s declaration applies only to "death-prolonging procedures" and only if the individual is terminally ill. This definitional approach requires the attending physician to make complex medical and personal judgments, but also imposes constraints on the physician’s discretion.

Second, the Act excludes from "death-prolonging procedures" those procedures that provide comfort care or alleviate pain and those that provide nutrition and hydration. The article notes that in certain circumstances, withholding nutrition or hydration may be consistent with the patient’s best interests. Courts have the task of developing a legal framework for this broadly stated limitation, and should uphold a patient’s express directive to withhold nutrition or hydration in certain circumstances.

A third limitation allows providers to act contrary to a declaration for a "serious reason therefore, consistent with the best interest of the declarant." The article explains that this narrow limitation does not grant the provider broad discretion to ignore a declaration based on personal beliefs or the wishes of the declarant’s spouse or family. Except in very limited circumstances, guardianship proceedings are not a sufficient basis to act contrary to a declaration.

Fourth and finally, the Act may provide statutory penalties to deter noncompliance with valid declarations. The Act describes noncompliance as "unprofessional conduct." Professional boards should treat such “unprofessional conduct” as synonymous with the “misconduct” contemplated in the Missouri Medical Practice Act and Nurse Practice Act, thereby establishing noncompliance with declarations as grounds for disciplinary actions.

Part IV addresses the scope of the Act. The Act creates one method by which the rights of the incompetent may be exercised, but it expressly states that it will not "impair or supersede" those rights. Limitations in the statute narrow the scope of the method employed rather than the underlying right itself.