DECISIONS AT THE END OF LIFE ESSAY

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DECISIONS AT THE END OF LIFE ESSAY

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The grieving patient may become withdrawn at this time.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.

 

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