1. Death and Dying
CH 13

2. The ethical issues relating to death and dying are especially sensitive. The one point of agreement that people have when discussing these sensitive issues is that the dying patient must be treated with dignity. This chapter includes information on the dying process, definitions of death, the stages of dying, quality-of-life issues, the use of medications for the dying patient, hospice care, palliative care, viatical settlements, advance directives, choices of life and death, the death certificate, and medical examiner cases.

3. I. The Dying Process
A. Expired means “died.” B. Modern medicine has enabled people to live longer and survive illnesses that once caused death. This has created some ethical and moral dilemmas. C. Legal definition of death 1. The actual determination of death has also become critical in the past few decades due to advances in medicine such as organ transplantation and life-support systems. 2. Karen Ann Quinlan Case (1975) a. Represented the first time a family requested the court to approve the removal of a respirator from a permanently comatose patient and won the case. b. Comatose is a word used to refer to a person who is in a permanently vegetative state. c. EEG—an electroencephalogram is a test that measures brain activity. .

4. determination that death has occurred.
3. Criteria for death—Certain criteria or standards assist in the
determination that death has occurred.
a. Rigor mortis or stiffness that occurs in a dead body.
b. Loss of heartbeat.
c. Loss of body color.
4. Debate over using cardiac definition or brain-oriented
definition of death.
a. Cardiac death occurs when the heart has stopped
functioning.
b. However, many people believe that a cardiac-oriented
definition of death is inadequate

5. a. Means that death occurs when there is irreversible cessation
5. Brain-oriented death
a. Means that death occurs when there is irreversible cessation
of all brain function.
b. Also found in irreversible coma.
c. Harvard Criteria used for a definition of irreversible coma includes
consideration of the following:
i. Whether the patient is unreceptive and unresponsive with
a total unawareness of externally applied, and even
painful, stimuli.
ii. Whether the patient has no spontaneous movements or
breathing, as well as an absence of response to stimuli
such as pain, touch, sound, or light.
iii. Whether the patient has no reflexes with fixed dilated
pupils, lack of eye movement, and lack of deep tendon
reflexes.

6. 6. Uniform Determination of Death Act a
6. Uniform Determination of Death Act a. Many groups object to the brain-death criterion. b. This act says that an individual is dead if the individual has sustained either i. Irreversible cessation of circulatory and respiratory function, OR ii. Irreversible cessation of all function of the entire brain, including the brain stem.

7. D. Withdrawing versus withholding treatment 1
D. Withdrawing versus withholding treatment 1. Withdrawing life-sustaining treatment means to discontinue it after it has started. 2. Withholding life-sustaining treatment never starting treatment. E. Active euthanasia versus passive euthanasia 1. Active euthanasia, the intentional killing of the terminally ill such as by a lethal dose of medication, is illegal in all jurisdictions in the United States, with the possible exception of Oregon. 2. Passive euthanasia, or allowing a patient to die naturally, is legal everywhere. Includes withholding basic needs such as artificial hydration and artificial nutritional needs.

8. F. The slippery slope argument of assisted suicide 1
F. The slippery slope argument of assisted suicide 1. Some ethicists argue that if society allows assisted suicide, it could lead to legalized murder. 2. The “slippery slope” might eventually allow us to “slip back” and have a diminished respect for life. G. Direct versus indirect killing 1. The double-effect doctrine recognizes that an action may have two consequences: one desired (and intended) and one undesired (and unintended). 2. An “act” can be an act of omission. H. Ordinary versus extraordinary means 1. Ordinary means—The term ordinary refers to a treatment or procedure that is morally required, such as fluids and comfort measures. 2. Extraordinary measures refer to those procedures and treatments that are morally expendable (do not serve any useful purpose, such as using further chemotherapy in the final days of a cancer patient’s life).

9. I. Right to die legislation or right to refuse treatment—Courts have rules that patients must be mentally competent in order to make their own decisions. J. Stages of dying—Dr. Elisabeth Kübler-Ross devoted much of her life to studying the dying process. She divided the process into five stages that she believed the patient, family members, and caregivers all go through. 1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance

10. III. Use of Medications
A. Physicians reluctant to prescribe heavy doses of narcotics for terminal patients due to fear of addiction. B. New belief that dying patient’s pain should be controlled with adequate medication.

11. IV. Hospice Care
A. Originated in France to keep a terminal patient as pain free as possible B. Called “death with dignity.” C. Focus on comfort measures, emotional support, and pain-free environment.

12. V. Palliative Care
A. The total care of patients whose disease is no longer responsive to curative therapy. B. Care for the terminally ill patient consisting of comfort measures and symptom control.

13. VI. Viatical Settlements—Allow people with terminal illnesses, such as AIDS, to obtain money from their life insurance policies by selling them. VII. Advance Directives—Also known as living wills. VIII. Choices of Life and Death A. Suicide B. The case of the conjoined twins IX. Mechanical Heart Recipient—First mechanical heart was implanted into a 59-year-old man, Robert Tools, in 2002.