END OF LİFE ETHICAL DILEMMA Assist.Prof.Dr. Mehmet KARATAS Dept. of History of Medicine & Ethics

Euthanasia CPR (Cardiopulmonary Resuscitation) DNR (Do Not Resuscitate) Futility Treatment

Definition of Death Irreversible loss of consciousness, loss of spontaneous breathing with the loss of heartbeat The death or loss of brain cells are necessary for the determination of death in medical terms Brain death occurs in every death

Possible Reasons for Brain Death Acute myocardial infarction, bradycardia, tachyarrhythmia, hypothermia, hyperthermia, anaphylaxis, cerebral attacks, anesthesia, trauma, electric shock, lightning strike, drowning in water, electrolyte disturbances, renal failure, toxic causes Elderness Chronic Diseases etc.

Determination of Brain Death EEG (Electro Encephalogram) Angiography

Determination of Brain Death Cornea Pupils Oculo-vestibular reflex

Brain Death Cortex (upper brain) death: There are light reflexes, no awareness, and eyes can follow objects when open, can live more than ten years The brain stem (lower brain) death: Light reflex, unconsciousness and no feelings, eyes closed, no spontaneous breathing

Determination of Death Anaesthetist Neurologist or Brain Surgeon

Ethical Dilemma Experienced Cases Cancer patients Terminally ill chronic patients Psychiatry patients Elders Congenital Anomalies

Case 1: Mr A Lung Cancer Diabetic Hypertensive Hemothorax Bleeding in head Fracture in extremeties Unconscious

CPR: Cardiopulmonary Resuscitation Basic Life Support Advanced Life Support

http://depts.washington.edu/learncpr/quickcpr.html

DNR: Do Not Resuscitate Should not be under 18 Should not be pregnant Have to have chronical disease in terminal period Two witnesses must consent

EUTHANASIA Painless death in Greek

World Euthanasia Application In 06.03.2006, the Dutch government decided to allow physicians to overdose of morphine to terminate babies who develop fatal diseases in order to relief the suffering. http://www.tumgazeteler.com/fc/ln.cgi?cat=33&a=1379914 Sunday Times

CASE 2: Dr. Chabot (Dutsch Psychiatrist) Lawsuit Patient B. is 50 years old Has 2 sons and a problematic marriage Her oldest son committed suicide in 1986 She had psychiatric treatment Lost her father in 1988 She left her husband and took her younger son with her After a car accident in 1990, her son was diagnosed with cancer. Her son died in 1991

Dr. CHABOT lawsuit Patient B. attempted suicide, but failed. She searched other methods to end her life, but she was afraid that another unsuccessful suicide trial would end her up in a mental hospital. Patient B. has applied for Voluntary Euthanasia Union and mentioned her desire for death.

Dr. CHABOT lawsuit Dr. Chabot was reprimanded by Medical Disciplinary Court for disturbing the confidence on medical profession The Supreme Court allowed physicians to help end the lives of the patients with non-fatal diseases and who has not somatic originated pain.

CASE 3: Trisomy 18 (Edwards syndrome) (1\6000) Premature birth Apnea Cardiac (VSD), GİS, renal anomalies Microcephaly, micrognathia, ear malformations, deformed hands, small size, facial asymmetry 30% of them will die in a month, 90% of them will die in a year.

Edwards syndrome

Opodyme

Legal Basis International Documents The Law on the Practice of Medicine and Medical Sciences Medical Ethics Charter Patients' Rights Directive Turkish Penal Code Turkish Medical Association Code of Professional Ethics in Medicine

Basic Ethic Principles Respect for Autonomy Beneficience Non-maleficence Justice

References F. Başak ÇAKMAK/Bilal GÜNENÇ, İnönü Üniversitesi Tıp Fakültesi, translation Tolga GÜVEN, Marmara Üniversitesi Tıp Tarihi ve Etik AD ders notları Gürkan SERT, Hasta Hakları Robert M VEATCH, Medical Ethics Emine ATABEK, Mebrure DEĞER, Tıbbi Deontoloji Konuları Hasta Hakları Yönetmeliği, 1998 Klinik Araştırmalar Hakkında Yönetmelik, 2011 Çağlar Boyu Tıp, Roche Yayınları http://en.wikipedia.org/wiki/Main_Page