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

2. 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.
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3. 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.

4. 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

5. 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

6. 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
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7. 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

8. 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

9. 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

10. 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
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11. 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
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12. 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
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13. 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

14. 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

15. 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

16. 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
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17. Active Euthanasia Versus Passive Euthanasia
Allowing patient to die naturally is legal

18. 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

19. 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
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20. 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

21. 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

22. 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
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23. Direct Versus Indirect Killing
Double-effect doctrine
An action may have two consequences, one desired (and intended) and one undesired (and unintended)

24. Ordinary Versus Extraordinary Means
Treatment or procedure that is morally required, such as supplying fluids and comfort measures, may be called appropriate
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25. 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

26. 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

27. Stages of Dying
According to Dr. Elizabeth Kübler-Ross, dying process is divided into five stages patient, family members, and caregivers all experience
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28. 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

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

30. 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

31. 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
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32. 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

33. 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

34. 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
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35. Viatical Settlements
Many use money to provide for medical and nursing care during final illness

36. 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

37. 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
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38. 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
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39. 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

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

41. 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

42. 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