The ethical issues relating to death and dying are especially sensitive. The one point of agreement that people have when discussing these sensitive issues is that the dying patient must be treated with dignity. This chapter includes information on the dying process, definitions of death, the stages of dying, quality-of-life issues, the use of medications for the dying patient, hospice care, palliative care, viatical settlements, advance directives, choices of life and death, the death certificate, and medical examiner cases.
—actively ending the life of or killing a patient who is terminally ill.
Legal only in Oregon and Washington and only under certain circumstances.
—an irreversible coma from which a patient does not recover; results in the cessation of brain activity.
—care for terminally ill patients consisting of comfort measures and symptom control.
—allowing a patient to die by forgoing treatment (including hydration and nutritional feeding). The patient is kept as comfortable and pain free as possible. The dying process is neither inhibited nor accelerated.
• Legal in all 50 states.
• The Roman Catholic Church prefers the phrase "allow to die" instead of passive euthanasia
Quality of life
—the physiological status, emotional well-being, functional status, and life, in general, of the individual.
Substitute judgment rule
—used when decision must be made for a person who cannot make his or her wishes known.
• A person, committee, or institution will attempt to determine what the person would do if she or he were competent
• These are open to debate
—one whose death is determined to be inevitable.
There are several ethical considerations for the terminally ill:
• withdrawing versus withholding treatment
• active euthanasia versus passive euthanasia
• direct versus indirect killing
• ordinary versus extra ordinary means
—allow people with terminal illnesses, such as AIDS, to obtain money from their life insurance
Withdrawing life-sustaining treatment
—discontinuing a treatment or procedure, such as artificial ventilation, after it has started.
Withholding life-sustaining treatment
—failing to start a treatment or procedure, such as artificial ventilation.
Discuss the difference between cardiac and brain-oriented death.
Cardiac death, or the legal definition of death, occurs when the heart has stopped functioning.
Brain-oriented death occurs when there is an irreversible cessation of all brain function. This does not necessarily mean that the heart has stopped functioning.
Describe the Harvard criteria for a definition of irreversible coma.
Based on this criteria, the considerations include whether the patient
a. Is unreceptive and unresponsive, with a total unawareness of externally applied, and even painful, stimuli.
b. Has no spontaneous movements or breathing as well as an absence of response to stimuli such as pain, touch, sound, or light.
c. Has no reflexes, with fixed dilated pupils, lack of eye movement, and lack of deep tendon reflexes.
Discuss the pros and cons of euthanasia.
Could include the following:
Arguments made by people in favor:
a. Respect for patient self-determination.
b. Provides a means for harvesting viable organs.
c. Provides relief for the family of a patient with an irreversible condition or terminal disease.
d. Provides a means to end a terminally ill person's suffering.
Arguments made by people in opposition:
a. There is no certainty regarding death.
b. Modern technology may find a cure for a terminal disease.
c. Families undergoing financial strain due to the burden of a dying relative may use euthanasia to relieve the financial burden.
d. Euthanasia might be used indiscriminately.
e. It is not good for society to allow physicians to kill patients or patients to kill themselves.
f. There is value and dignity in human life.
g.The sick and dying may have a fear of involuntary euthanasia if euthanasia is legalized.
h. Only God has domination over life.
Provide examples of ordinary versus extraordinary means used in the treatment of the terminally ill.
Ordinary means include fluids, pain-reducing medications, and comfort measures such as turning patients.
Extraordinary means include respirators, feeding tubes, chemotherapy, and intravenous therapy.
List and discuss the five stages of dying as described by Dr. Kübler-Ross.
a. Denial—a refusal to believe that dying is taking place.
b. Anger—at this stage, the patient may be angry with everyone and may express an intense anger toward God and even healthcare professionals.
c. Bargaining—this involves attempting to gain time by making promises to God in return for a cure.
d. Depression—there is a deep sadness over the loss of health, independence, and eventually life.
e. Acceptance—this stage is reached when there is a sense of peace and calm.
Discuss eleven treatments that might be ordered for the critically or terminally ill.
a.Cardiopulmonary resuscitation (CPR)—a lifesaving technique for accident and heart attack victims when their hearts have stopped beating. It consists of applying chest compressions and ventilation into the mouth until the heart begins to beat again.
b. Mechanical breathing or respirator—a mechanical device used for artificial ventilation of the lungs.
c.Tube feedings—nutritional support that consists of placing a tube within the patient's stomach either through the nose or directly into the gastrointestinal system.
d. Kidney dialysis—a medical treatment in which impurities or waste matter are removed from the patient's blood when the kidneys fail to function.
e. Chemotherapy—the use of chemicals that have a toxic effect on disease- producing organisms, such as cancer.
f. Intravenous therapy—the administration of fluids by means of a tube inserted into the vein.
g.Surgery—an invasive procedure, usually conducted under a general anesthetic, to remove a diseased organ or tissue, to repair the body, or as a diagnostic tool.
h. Diagnostic tests—medical tests that help to determine the cause of a disease or abnormality.
i. Antibiotics—medications used to fight disease and ward off illnesses such as pneumonia.
j. Transfusions—the replacement of blood for ailments such as severe anemia or hemorrhage.
k. Pain medications and palliative care—care used to relieve pain and discomfort.
The Dying Process
Professional codes of ethics include a statement about the healthcare professional's duty to preserve the dignity and life of the patient.
Legal Definition of Death
• A corpse, or body of a deceased person, must still be treated with respect.
• Determination of death is critical for practical as well as legal reasons.
Devices (e.g., ventilators/respirators and feeding tubes) that allow medical practitioners to for additional weeks, months, or years a person who according to all traditional standards, has died.
Karen Ann Quinlan Case
• In 1975 suffered cardiopulmonary arrest and was placed on a respirator. She was able to breath through a tracheotomy and receive nutrition though a nasograstric feeding tube. She was considered to be comatose, or permanently vegetative state. Her brain activity, measured by EEG, was abnormal but brain scans showed activity to be within normal limits. Many legal battles took place while trying to decide whether to discontinue use of the respirator. When it was finally removed, Karen continued to breath on her own. She was kept alive, but unresponsive, with the feeding tube for another ten years.
Insertion of a nasogastric tube is a serious decision when the patient is comatose. It provides life-extending treatment. Determining if the patient is incompetent to decide whether to remove the tube or not created an ethical dilemma.
The right to accept or reject medical treatment is each person's fundamental right.
Criteria for Death
Criteria for death include:
• loss of heartbeat
• significant drop in body temperature
• no pupil response to light
• loss of body color
• no response to pain
• rigor mortis
• biological disintegration
These symptoms may not occur until hours after death, or not at all if the body is on life-support.
Death must be determined before organs can be transplanted
Certain circumstance may make a person appear dead, such as with hypothermia, when they are not.
There is controversy over whether to use a cardiac definition of death or a brain-oriented definition.
• Death defined by the cessation heart function; irreversible cessation of respirator and circulatory function. A cardiac death is considered a legal death in most situations.
• There may be irreversible loss of cardiac function, but loss of breathing and pulse are reversible.
• The terms cardiac (heart) and cardiopulmonary (heart and lung) are interchangeable as a legal definition of death.
• A problem with the cardiac definition is the way it affects organ donation. If a surgeon waits until all cardiac function has ceased, the organs will likely be unusable. This alone is not reason to change the legal definition of death. Many people believe the cardiac definition is inadequate.
• Under this definition, death occurs when there is irreversible cessation of all brain functions. Most states accept this definition (except NJ). This is gaining favor as the preferred definition in many countries, including the U.S.
• Heart and lung function can be maintained for hours or days after all brain function has stopped.
Persistent vegetative state (PVS)
In most states, if the whole brain is dead, the person is considered deceased. When PVS, an irreversible brain condition in which the patient is in a state of deep unconsciousness, persists, it is almost always irreversible.
• PVS is only diagnosed when several neurologists concur and the patient has been in a coma for over six months.
• An ethical dilemma arises when a patient has no brain activity, but whose heart and respiratory functions can be maintained by mechanical means.If the life supporting devices are removed the patient will suffer cardiac death too. The issues is when to consider the person dead.
The Harvard Criteria for a Definition of Irreversible Coma
Considered whether the patient:
1. Is unreceptive and unresponsive, with a total unawareness of externally applied, and even painful stimuli.
2. Has no spontaneous movements or breathing, as well as an absence of response to stimuli such as pain, touch, sound, or light.
3. Has no reflexes, has fixed dilated pupils, lack of eye movement, and lack of deep tendon reflexes.
• An EEG is used to determine the absence of brain activity and then repeated after 24 hours.
• No patients diagnosed with this criteria have been know to recover.
• This irreversible coma is called brain death.
• A patient must be declared brain dead before life support can be removed.
• Even the Harvard Criteria is under scrutiny because they are the main method for determining a person's eligibility to become an organ donor and there are patients who are in a PVS but may show some evidence of consciousness.
• Also, recent studies indicate that some VPS patients may be unresponsive and still have brain activity indicating awareness and even a wish to communicate.
• Currently as many as 37,000 people in the U.S. are in PVS or minimally conscious state.
• To protect both the patient and the physician, an outside medical opinion should be sought before terminating life-support.
Uniform Determination of Death Act (UDDA)
• The American Bar Association, The American Medical Association, the Uniform Law Commissioners, and the American Academy of Neurology, among others approved of this act.
• The UDDA says an individual who has sustained either (1) irreversible cessation of circulatory and respirator functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead.
• Right-to-lifers (Orthodox Jews, Catholics, etc.) object to brain-death criteria because it could leave the door open for euthanasia and abortion.
Withdrawing versus Withholding Treatment
• HCPs (health care professionals) often find it more difficult to withdraw treatment than to withhold it. Withdrawing treatment sometimes requires a court order.
• Starting life-sustaining treatment allows the HCP more time to evaluate the patient's condition.
• Patients have the legal right to refuse treatment as well as food.
Active Euthanasia versus Passive Euthanasia
• eu means good and thanatos means death = good death
• Synonyms for euthanasia = assisted suicide, right to die, and aid-in-dying.
• Oregon and Washington are the only states where active euthanasia (e.g., injected lethal doses of medication) it is legal.
• People who see euthanasia as ethical equate it with humane treatment of terminally ill patients in order to put an end to their suffering and pain.
• People who view euthanasia as unethical equate it with murder.
• Most people believe there is a distinction between actively killing a patient (active euthanasia or assisted suicide) and allowing a patient to die by forgoing treatment (passive euthanasia).
• This distinction is approved by the AMA, Roman Catholic moral theology, and the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research.
Physician Assisted Suicide (PAS)
Initiative 1000 or Washington's Die with Dignity Act allows PAS.
Slippery Slope Argument of Assisted Suicide
• The argument against assisted suicide is that it diminishes our respect for life.
• The fear is that once it is acceptable for terminally ill patients, that it will eventually grow to include patients who are not terminally ill, like the elderly, disabled, or unproductive.
A document that is meant to prevent medical staff from using "extraordinary" measures, such as ventilators to keep someone alive.
When families ask what to do
The physician is the only HCP who can advice the patients or their families on a course of medical treatment.
Direct versus Indirect Killing
• A medical action can have two effects; one that is intended/desirable and one that is unintended/undesirable.
• A death can result from a person's action or inaction.
• A death can also be an unintentional result of a person's action.
• The AMA and the Catholic Church oppose direct killing but accept undesired and unintended deaths. Courts generally do too.
Principle of Double Effect
Recognizes that an action may have two consequences, one desired (and intended or morally good) and one undesired (and unintended).
Ordinary versus Extraordinary Means
• Ordinary (or appropriate) refers to a treatment or procedure that is morally required, such as fluids and comfort measures.
• Extraordinary (or inappropriate) measures refer to those procedures and treatments
that are morally expendable.
• Depending on the situation the exact same treatment may be considered to be either ordinary or extraordinary.
• A treatment may serve a useful purpose by prolonging life, but it may not be morally justified if it involves a grave burden. (Pope Pius XII & the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research.)
Right to Die Legislation or Right to Refuse Treatment
• Patients have the right to refuse treatment.
• Sometimes when the patient's refusal places their life in danger, legal action sometimes results.
Stages of Dying
p. 333 Table 13.1
There are five stages of dying/grief that patients, family, and caregivers go through.
• These stages can overlap or be experienced in a different order.
Measures to assess quality of life are intended to help make healthcare decisions based on more than clinical factors and costs. They are:
• General health
• Physical functioning
• Role limitations, such as within the family structure
• Social function
• Mental health
To quality of life measurement tools are the Functional Living Index (FLIC) and the Arthritis Impact Measurement Scale (AIMS).
Use of Medications
• Physicians often believe that relieving a dying patient's suffering with potentially addictive medications takes precedence over the possibility of addiction.
A multidisciplinary, family-centered care, is a system designed to provide care and supportive services for terminally ill patients and their families. Advertised as "death with dignity", hospice focuses on comfort measures and emotional support.
• New evidence shows that patients can be kept almost pain free at the end of their lives with carefully managed medication control.
• Services include pastoral and respite care for the family.
The total care of patients whose disease is no longer responsive to curative therapy. It consists of comfort measures meant to provide relief of pain and suffering.
• Some people think that the aggressive treatment of elderly patients is inhumane.
A process that allows people with terminal illnesses, such as AIDS, to obtain money from their life insurance policies by selling them.
• A 20 to 50 percent discount is given on the face value of the patient's insurance policy so the patient can have immediate access to the money.
• The patient names the settlement company as the recipient of the death benefit. It company assumes responsibility of the policy, including making the payments. At the time of the patients death, the company gets the death benefit.
• The cons of viatical settlements are tax liabilities and potential loss of entitlements like Medicaid.
• It is a gamble because the patient may receive only a portion of the policies worth and may outlive the amount they do receive.
The Federal Patient Self-Determination Act of 1991 mandates that adult patients admitted into any healthcare facility that receives funding from Medicare o Medicaid must be asked if they have an advance directive or wish to have information about these self-determination directives.
• Documents such as a living will (advance directive), durable power of attorney for healthcare, Uniform Anatomical Gift Act and do not resuscitate (DNR) must be completed after the patient enters the facility.
• Must be in writing
• Courts typically enforce them
• Patients may also write a directive requesting the maximum care available
• Without an advanced directive patients could receive CPR, respirator, feeding tubes, dialysis, chemo, iv therapy, surgery, diagnostic tests, antibiotics, and transfusions.
• Everyone over 18 should have an advanced directive with specifications about CPR, tube feedings, and ventilators.
Living will or advance directive
Advance directives limit he type and amount of medical care and treatment that patients will receive if they should become incompetent and have a poor prognosis.
• Suicide is considered to be morally wrong and is illegal in most states.However, no state currently punishes people who try to commit suicide.