Decisions at the End of Life Essay

Decisions at the End of Life Essay Assignments

 

Assignment 1: Review Question A

Assignment 2: Review Question B

Assignment 3: In the News, Page 215

Assignment 4: Case Study, Page 224

Assignment 5: Legal Case Study, Page 230

Assignment 6: Please read The New York Times article, “Seeking a ‘Beautiful’ Death” by Jane Brody, February 9, 2015

Assignment 7: Please read The New York Times article “When ‘Doing Everything’ Is Way Too Much” by Jessica Nutik Zitter, February 7,2015.

 

Life

• Redefining the concept of life.
• Common measures of the quality of life:
  • Fulfillment
  • Satisfaction/dissatisfaction
  • Conditions of life
  • Happiness/unhappiness
  • Experiences of life
• Biological life
  • • Is the life we share with all other living things, it is not unique to humans?
    • It separates us from rocks and elements, and separates the world into living and nonliving things.
    • Humans, plants and animals are living in this sense; rocks are not.
• Not uniquely human.
• Biographical life
  • Is in terms of events, memories, and interactions which are uniquely human.
  • It is our life and separates us from other life forms, and it makes us uniquely human.

 

Stages of Dying

• Dr. Elizabeth Kubler-Ross devoted her life to the study of the dying process and she divided the dying process into five stages:
•  Denial
  • A refusal to believe that dying is taking place.
  • This may be at a time when the patient (or family member) needs time to adjust to the reality of approaching death.
  • This stage cannot be hurried.
• Anger
  • The patient may be angry with everyone and may express an intense anger toward G-d, family, and even health care professionals.
  • The patient may take this anger out on the person closest to them, usually a family member.
  • In reality, the patient is angry about dying.
• Bargaining
  • This involves attempting to gain time by making promises in return.
  • Bargaining may be done between the patient and G-d.
  • The patient may indicate a need to talk at this stage.
• Depression
  • There is a deep sadness over the loss of health, independence, and eventually life.
  • There is an additional sadness of leaving loved ones behind.
  • The grieving patient may become withdrawn at this time.
• Acceptance
  • This stage is reached when there us a sense of peace and calm.
  • The patient makes such comments as “I have no regrets, I am ready to die.”
  • It is better to let the patient talk and not to make denial statements such as “Don’t talk like that.  You’re not going to die.”

 

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Standards for Death

• Cardiopulmonary standard
  • Classic standard
  • Loss of cardiac and pulmonary function
  • Society has moved away from cardiopulmonary standard of death to brain death
• Brain death
  • Irreversible cessation of all functions of the entire brain, including the brain stem.
• Harvard Medical School Brain Death Test
  • Unreceptive and unresponsive
  • No movements or breathing
  • No reflexes
  • Flat EEG of confirmatory value

Death Certificate

• The physician or coroner should prepare the following information for the death certificate.
  • Name and address of deceased
  • Age
  • Place and date of birth
  • Names of parents (including mother’s maiden name)
  • Birthplace of parents
  • Race
  • Deceased’s occupation
• This information is maintained for statistical and epidemiological purposes.
• After the physician has completed this information, the mortician types the final death certificate and the physician signs and dates it.
• Most states do not allow the body to be buried until the death certificate is signed
• Certified death certificates cost about $10.00/each and are necessary for closing up estates, bank accounts, stock accounts, etc.

Medical Examiner Cases

• Every state provides for a legal investigation by a medical examiner or coroner in cases of suspicious death.
• A physician reports any suspicious deaths to the medical examiner.
• Suspicious cases include death:
  • Of a violent nature, including homicide, suicide or accident
  • Caused by criminal abortion
  • Related to contagious or virulent diseases that may cause a public health hazard
  • Of a person confined to jail or other correctional institution
  • Resulting from an unexplained or unexpected cause
  • Caused by electrical, chemical or radiation injury
  • Of a person who had not had a physician un attendance within 36 hours of death
  • Of a person whose body is not claimed by a friend or relative
  • Of a child under the age of two years if death results from an unknown cause
  • Of a person of unknown identity

Brain Death – Clinical Problem

• Brain-dead patients are often problematic to families
  • Heart often in sinus rhythm
  • Ventilator stimulates breathing
  • Patient may have the appearance of life
  • The body ceases the function when ventilatory support is discontinued
• Practitioners must shift concern from the deceased patient to the grieving families.
• Brain death is an irreversible form of unconsciousness, characterized by a complete loss of brain function, while the heart continues to beat.
• There are no reflexes present and no movements of breathing.
• There is a total unreceptively and unresponsiveness and a flat EEG.

 

 

Neocortical Death

• Some call for a new standard for death
  • The irreversible loss of higher brain function
• Many patients in persistent vegetative state (PVS) would be judged to be dead
• The acceptance of a neocortical standard would necessitate additional movement toward active euthanasia, for which there is currently no societal consensus.

Persistent Vegetative State (PVS)

• PVS occurs when there is no recognizable cognitive function.

• PVS suggests irreversible loss of neocortical function;
  • Permanent eyes-open state of unconsciousness
  • Patients are not comatose
  • Patients are awake, but unaware
  • Generally brain stem continues to function, patient breathes, elicitable reflexes, reactions to external stimuli
  • Patients continue to breath when ordinary care devices are removed
• PVS does not meet brain death criteria
  • Remote chance for recovery

 

Karen Ann Quinlan

• PVS patient
  • Family request to have her removed from the “extraordinary means.”
  • Court decision and rationale
  • Outcome
• Ordinary care vs. extraordinary care
• What is the difference?

 

Ordinary Care

• All medicines, treatments, and operations that offer reasonable hope or benefit.
  • Obtained without excessive expense
  • Without excessive pain
  • Without other inconvenience

 

Extraordinary Care

• All medicines, treatments, and operations that cannot be obtained or used without:
  • Excessive expense
  • Excessive pain
  • Excessive inconvenience
• If used, would not offer reasonable hope or benefit.
• Most care beyond palliative care.
  • Palliative care is designed to relieve symptoms of disease rather than to cure the disease

 

 

Ordinary and Extraordinary Means

• It is generally held that one can ethically forgo extraordinary means but us obligated to continue ordinary means of care.
  • If care offers no potential benefit, would it be by definition extraordinary?
  • Could hydration and nutrition be considered extraordinary?

Proxy Decision-Making Standards

• Substituted-judgment standard.
  • Person at one time capable of making decision
  • Karen Ann Quinlan
• Best interest standard.
  • Person never in situation where an authentic choice could be made
  • Joseph Saikewicz

 

Informed Nonconsent

• What is to be done when a competent adult, after having been informed in regard to their need for lifesaving care, refuses?
  • William Bartling
  • Elizabeth Bouvia
• Court ruling:
  • Patient acuity is irrelevant to the allowance of refusal
  • Patient’s perception of his or her quality of life and treatment requirements are of paramount importance
  • No meaningful legal distinction between mechanical life support and nasogastric feeding tube
  • Distinctions between withholding and withdrawing care are legally irrelevant

 

Baby Doe

• Baby Doe case
• Interim Final Rule and “Baby Doe squads”
• Child abuse Amendment guidelines.
• Government ruling returns decision making to parents and physicians.

 

Organ Donation

• Ongoing shortage one of the most discussed bioethical issues today and relates to whom shall receive an organ transplant.
• These procedures are some of the most expensive of all medical procedures.
• Liver transplants cost about $250,000,in addition, the follow up care to aid the transplant by suppressing the immune system can cost another $20,000to $30,000 a year
  • Demand for organs greater than the supply of organs
  • Criteria for determining death becomes critical
  • Policy of volunteerism
  • Uniformed Anatomical Gift Act
    • See page 8
  • United Network for Organ Sharing (UNOS)
    • Is the legal entity in the United States responsible for allocating organs for transplantation
  • National Organ Transplant Law of 1984
    • Forbids the sale of organs un interstate commerce,
    • Protects the poor from being exploited, since they may be tempted to earn money by what they believe to be unneeded organs, such as a kidney.
• Proposals for policy change include:
  • Mandated choice on license or tax return
  • Presumed consent
  • Financial incentives
  • Xenografting – Xenotransplantation – refers to the use of animal organs as permanent replacements for human organs
  • Changing definition of death
  • Use of condemned prisoners

 

 

• Issues involving living donors
  • Long wait lists for organs raises questions of ethics
    • Does the scarcity of organs encourage prematurely declaring a person as brain dead?
    • What constitutes voluntary informed consent?
  • Involuntary harvesting of organs from indigent people and prisoners which occurs in some parts of the globe.
  • Organs are sold to procurement centers in affluent countries.
• Some people/family are in desperate straights for organ procurement.
• Families may be rushed in giving consent in sudden accidental death of a loved one.
  • Are they being coerced into organ donation?
  • Do the needs of the family take precedence over the time constraints in organ harvesting?

 

Personhood Proposal

• Some have argued for personhood criteria to settle PVS cases
  • Only persons can be thought of as beings that possess rights.
• Personhood criteria includes:
  • One who could be said to have interests
  • One who has cognitive awareness
  • One who is capable of relationships
  • One who has a sense of futurity

 

Nancy Cruzan

• Nancy Cruzan case
• Court decision:
  • State has the right to assert an unqualified interest in preserving human life.
  • Choice between life and death extremely personal (clear and convincing evidence).
  • Incompetent patients subject to abuse
• Decision led to increased interest and use of advanced directives.
• Advanced directives should provide clear and convincing evidence of choice
• Hydration and nutrition question
  • When treatment is futile
  • With no possibility of benefit

 

 

Advanced Directives

• The court’s decision on the Nancy Cruzan case, which called for clear and convincing evidence in regard to patient choice in these matters resulted in Advanced Directives

 

• Living will statements
  • Documents that a person drafts before becoming incompetent or unable to make health care decisions.
  • Hard to be inclusive for all situations.
  • Choice may change over time and change of circumstances (pregnancy).
  • Attempts to set forth your wishes for extraordinary care should you find yourself in a position where you can not make your wishes known.
  • May be somewhat limiting.
• Durable power of attorney (DPA)
  • The Durable power of attorney, when signed by the patient, allows an agent or representative to act on behalf of the patient.
  • The DPA continues even if the patient is physically or mentally incapacitated.
    • Copies should be kept with the patient’s record
    • Greater flexibility
    • Able to respond to a greater range of situations
  • The DPA empowers an individual who knows your wishes to make choices for you when you can not speak for yourself.
  • Combined forms provide direction when individuals loose the ability to make their wishes known.
• Uniform Anatomical Gift Act
  • Allows a person 18 years or older of sound mind to make a gift of any or all body parts for purposes of organ transplantation or medical research.
  • The statue includes two specific safeguards.
  • First, the time of death must be determined by a physician who is not involved in the transplant.
  • Second, no money is allowed to change hands for organ transplantation.
  • The donor carries a card that has been signed in the presence of two witnesses.
  • In some states the back of the license has a space to indicate the desire to be an organ donor.
  • If the person has not indicated a desire to be a donor, the family may consent on the patient’s behalf. (In cases of sudden, accidental death).
• Do Not Resuscitate orders (DNR)
  • This is an order given by the physician and placed in a person’s chart.
  • It indicates that a person does not wish to be resuscitated if breathing stops in a cardiac or pulmonary incident.
  • Language and guidelines, p. 217
• Patient Self-Determination Act of 1990 (PSDA)
  • Senator John Danforth (R-MO) drafted the PSDA as part of the Omnibus Reconciliation Act of 1990.
  • PSDA was designed to support the autonomous decision-making authority of patients in regard to accepting or refusing specific medical interventions when admitted to health care facilities receiving federal reimbursements under Medicaid and Medicare.  The legislation requires these facilities to:
    • Provide patients at the time of admissions with information concerning their right to accept or refuse medical interventions.  The facilities are charged with providing information and assistance in the preparation of advanced directives.
    • The facilities will create and maintain written institutional policies in regard to patient rights; they will provide education for the staff, patients, and community concerning advanced directives.
  • The patient’s wishes in regard to refusing of executing an advanced directive will be documented in the medical record. Decisions at the End of Life Essay Assignments.