Death and Dying 13 Journal Topic: Describe some the pros and cons of euthanasia.

Learning Objectives Define the key terms. Discuss the difference between cardiac and brain-oriented death. Describe the Harvard Criteria for a Definition of Irreversible Coma. Discuss the pros and cons of euthanasia. continued on next slide

Learning Objectives Provide examples of ordinary versus extraordinary means used in the treatment of the terminally ill. List and discuss the five stages of dying as described by Dr. Kübler-Ross.

The Dying Process Death is inevitable for everyone Modern medicine has enabled people to live longer and survive disease Patients can now be kept alive by medical technology Health care professionals have a duty to preserve life

Legal Definition of Death Determination of death is important for many reasons A person who has expired is no longer treated the same way as a living human Actual determination of death is critical due to organ transplantation and life-support systems Technology allows sustaining an otherwise "dead" person

Karen Ann Quinlan Case April 15, 1975 21-year-old, unconscious from a prescription drug and alcohol overdose Tracheotomy and respirator to help with breathing and nasogastric tube for nourishment Comatose, or permanently vegetative, condition continued on next slide

Karen Ann Quinlan Case Father appealed to have respirator discontinued Respirator discontinued, but feeding tube continued Lived in coma for ten years without respirator, then died

Criteria for Death Assist in determination that death has occurred Loss of heartbeat, significant drop in body temperature, loss of body color, rigor mortis (stiffness) Symptoms may not appear until several hours after death, or not at all if life-support equipment used

Cardiac Death Death in which heart has stopped functioning Lack of pulse or breathing Considered a legal death Irreversible loss of all cardiac function Serious problem for organ transplants

Brain-Oriented Death Death occurs when there is irreversible cessation of all brain function Persistent vegetative state (PVS) Most states accept this definition of death Heart and lung functions can be maintained by mechanical means after brain function has stopped continued on next slide

Brain-Oriented Death Harvard Criteria for Definition of Irreversible Coma Unreceptive and unresponsive with total unawareness of externally applied and painful stimuli No spontaneous movements or breathing, absence of response to pain, touch, sound, or light continued on next slide

Brain-Oriented Death Harvard Criteria for Definition of Irreversible Coma No reflexes, with fixed dilated pupils, lack of eye movement, and lack of deep tendon reflexes continued on next slide

Brain-Oriented Death Brain death Some ethicists believe that if there is some level of consciousness, then the patient is not dead Recent studies indicate that some vegetative patients may actually have brain activity

Uniform Determination of Death Act 1990 approved Individual is dead if he or she has sustained either: Irreversible cessation of circulatory and respiratory functions, or Irreversible cessation of all functions of the entire brain, including the brain stem

Withdrawing Versus Withholding Treatment Withdrawing means to discontinue treatment after it has been started Withholding means never starting treatment Many people believe both are ethically wrong Patients have the legal right to refuse treatment and food

Active Euthanasia Versus Passive Euthanasia Intentional killing of the terminally ill is illegal in all jurisdictions in the United States except Oregon and Washington Physician-assisted suicide (PAS) Physician provides patient with medical know-how or means to enable patient to end own life continued on next slide

Active Euthanasia Versus Passive Euthanasia Allowing patient to die naturally is legal

Slippery Slope Argument Concern with assisted suicide Might lead to a diminished respect for life Might "slip" into allowing a non-terminal patient to die

The Nancy Cruzan Case January 11, 1983 25-year-old injured in auto accident was left in vegetative state Feeding tube implanted Family requested feeding tube be removed continued on next slide

The Nancy Cruzan Case U.S. Supreme Court ruled against Cruzans New evidence of Nancy Cruzan not wishing to be maintained as in the Karen Quinlan case Feeding tube removed and Nancy Cruzan pronounced dead on December 26, 1990

The Terri Schiavo Case Woman in a persistent vegetative state Husband sought to have her feeding tube removed Tube was removed by court order Governor ordered tube to be reinserted Finally died after tube was removed

Direct Versus Indirect Killing Death is result of another person's intended action or inaction Indirect killing Death is result of unintentional action of another person continued on next slide

Direct Versus Indirect Killing Double-effect doctrine An action may have two consequences, one desired (and intended) and one undesired (and unintended)

Ordinary Versus Extraordinary Means Treatment or procedure that is morally required, such as supplying fluids and comfort measures, may be called appropriate continued on next slide

Ordinary Versus Extraordinary Means Extraordinary measures Procedures and treatment that are morally expendable, such as chemotherapy, tube feedings, CPR, and mechanical breathing or respirators, may be called inappropriate

Right to Die Legislation or Right to Refuse Treatment Patients have the right to refuse treatment If refusal places the patient's life in danger, legal action sometimes results

Stages of Dying According to Dr. Elizabeth Kübler-Ross, dying process is divided into five stages patient, family members, and caregivers all experience continued on next slide

Stages of Dying Stages may overlap and may not be experienced by everyone in stated order, but all are present in the dying patient: Denial Anger Bargaining Depression Acceptance

Quality-of-Life Issues Measures to assess quality of life include: General health Physical functioning Role limitations Bodily pain Social function Vitality Mental health

Use of Medications Dying patients often spend most of their last days in moderate or severe pain Physicians are often reluctant to overprescribe pain medications for fear patient may become addicted to drug Many physicians now believe patient's pain and suffering should be controlled with use of adequate medications

Hospice Care Designed to provide care and supportive services to terminally ill patients and their families Originated in France Committed to keeping patients with terminal illness as pain-free as possible continued on next slide

Hospice Care Focused on providing comfort measures, emotional support, and as pain-free as possible final environment for the patient Staff specially trained in caring for dying patients

Palliative Care Total care of patients whose disease is no longer responsive to curative care Consists of comfort measures Meant to provide a relief of pain and suffering so patient can die with dignity Emphasizes symptom control Opposite of curative care

Viatical Settlements Allow people with terminal illness to obtain money from life insurance policies by selling them In exchange for 20 to 50 percent discount on face value of patient's insurance policy, patient can have immediate access to money Patient names settlement company as recipient of death benefit continued on next slide

Viatical Settlements Many use money to provide for medical and nursing care during final illness

Advance Directives Documents such as living will, durable power of attorney for health care, Uniform Anatomical Gift Act, and do not resuscitate (DNR) orders Popularly known as living wills Limit type and amount of medical care and treatment patients will receive if they become incompetent and have poor prognosis

Choices in Life and Death Suicide Considered morally wrong and illegal in most states No state punishes people who attempt suicide, but they may be placed in psychiatric care if present danger to themselves Many religions condemn suicide and euthanasia continued on next slide

Choices in Life and Death Suicide Antidepressants and suicide Depression medicine may actually cause an increase in depression Gender Men are at a higher risk of suicide than women Age factor of children Older adults continued on next slide

Choices in Life and Death Suicide Risks for nonfatal suicide attempts 11 estimated suicide attempts for every suicide death Prevention Should be performed by trained professionals Medications and psychotherapy are the major treatments

Choices in Life and Death “Survivor’s Guilt” Could have been prevented Stigma or disgrace Family and friends may need counseling

The Case of Conjoined Twins Death resulted during procedure in July 2003 50-hour operation to separate 29-year-old twins joined at head Twins knew of risks but knowingly accepted risks Many ethical debates about the separation

Mechanical Heart Recipient Implanted in 59-year-old man in July 2001 Did well until he suffered severe strokes from blood clots Final days of life spent partly paralyzed and breathing through a ventilator Lived for five months with mechanical heart