1. Advance Directives Legal documents that allow you to convey your decisions about end-of-life care ahead of time – Dialysis, breathing, resuscitation, tube feeding, organ donation

2. Appointed Decision Makers When no person has been identified to make decisions for you, if you are unable, the court can appoint someone

3. Do-Not-Resuscitate (DNR) Order Given by a physician stated that in a cardiac or respiratory arrest no resuscitation measures should be taken

4. Durable Power of Attorney A legal document assigning someone to act on your behalf if you are unable to – Estate affairs, money, bills, legal affairs, – Specified amount of time

5. Euthanasia Intentionally ending a life in order to relieve pain and suffering

6. Futility of Treatment Physician recognizes that the effect of treatment will be of no benefit to the patient

7. Guardianship A legal mechanism by which the court declares a person incompetent and appoints a guardian – Financial, living, medical decisions all go to guardian

8. Health Care Proxy Allows you to appoint an “agent” to make treatment decisions for you in the event you cannot

9. Living Will Legal document that describes those treatments an individual wishes or does not wish to receive should he or she become incapacitated and unable to communicate treatment decisions

10. Oregon’s Death with Dignity Act Allows a terminally ill Oregon resident to obtain a lethal dose of medication from his or her physician

11. Patient Self-Determination Act Provides that patients have a right to formulate advance directives and to make decisions regarding their health care

12. Physician-Assisted Suicide An action in which a physician voluntarily aids a patient in bringing about his or her own death

13. Substituted Judgment A form of surrogate decision making where the surrogate attempts to establish what decision the patient would have made if that patient were competent to do so.

14. Surrogate Decision Maker An agent who acts on behalf of a patient who lacks the capacity to participate in a particular decision – Limited to specific instructions included in the proxy document

15. Withdrawal of Treatment A decision to discontinue treatment or medical interventions for the patient

16. End-of-Life “There is nothing more sacred than life and there is nothing more natural in life to wish to cling on to it for those you love! And nothing more cruel than to play god by artificially holding onto that which god wants to bring home.”

17. Euthanasia Intentionally ending a life in order to relieve pain and suffering Broad definition – “the mercy killing of the hopelessly ill, injured, or incapacitated

18. Euthanatos Greek Word: meaning “good death” or “easy death” – Acceptable for incurable diseases

19. Euthanasia Confucian and Buddhist –acceptable for unendurable pain and incurable disease Celtics – if you are diseased or senile and do not commit suicide you will be condemned to hell

20. Euthanasia Change in the late 1800’s – Napolean’s physician refused his plea to kill stating his commitment to cure

21. Euthanasia 2million die each year – 80% die in hospitals or nursing homes – 70% die after forgoing life-sustaining treatment

22. Active Vs. Passive Euthanasia Active: intentional act that results in death Passive: lifesaving treatment is withdrawn of withheld

23. Voluntary or Involuntary Euthanasia Voluntary: A person makes the decision to die Involuntary: decision to end life of incurable person is made by someone other than that person

24. Let’s Define Death Black’s Law Dictionary: “cessation of respiration, heartbeat, and certain indications of central nervous system activity, such as respiration and pulsation.”

25. Brain Death AMA 1974: Death occurs when there is “irreversible cessation of all brain functions including the brain stem.”

26. Assisted Suicide Physician prescribes a lethal dose of medication to be taken by a mentally competent patient with a terminal illness Legal in – Oregon, Washington, and Montana

27. Physician Assisted Suicide Physician Protection: – Patients consent and deliver medication – Therefore physicians are shielded from homicide liability

28. Physician Assisted Suicide U.S. Supreme Court: ruled that states can allow physicians to assist in the suicide of their terminally ill patients

29. Physician Assisted Suicide Dr. Kevorkian: – As of March 1998, aided in or witnessed more than 100 suicides – Said “dying is not a crime” – Served 8 years in jail – Michigan did not have a law against it

30. Dr. Kevorkian http://www.cbsnews.com/8301-504803_162- 20068720-10391709.html http://www.cbsnews.com/8301-504803_162- 20068720-10391709.html

31. Homework Read and Comment on Hanna, Gary, and Caitlin

32. Oregon’s Death with Dignity Act Allows a terminally ill Oregon resident to obtain a lethal dose of medication from his or her physician

33. Oregon’s Death with Dignity Act Passed on October 27 th 1997 Specifically prohibits euthanasia

34. Oregon’s Death with Dignity Act Terminal disease – death within 6months Mentally competent adult Resident of Oregon Attending and consulting physician Make a written request

35. Oregon’s Death with Dignity Act Request witnessed by two individuals Pt receive full information from physician Both written and oral request from the patient – First pt makes and oral and written then must make an additional oral request within 15 days of original request

36. Oregon’s Death with Dignity Act Physician give patient the opportunity to rescind the request 15 day waiting period

37. Ethicists View Those who advocate the prohibition on taking action to shorten life agree that “where death is imminent and inevitable, it is permissible to forgo treatments that would only provide a precarious and painful prolongation of life, as long as the normal care due to the sick person in similar cases is not interrupted.”

38. Futility of Treatment Physician recognizes that the effect of treatment will be of no benefit to the patients Inform patient of little likelihood of success

39. Futility of Treatment Forgoing life-support measures is simply a decision that the dying process will not be artificially extended Decision can be made only be the surrogate Decision as to futility of tx can be made only by the physician p 148

40. Withdrawal of Treatment Considered when: – 1) terminal condition and reasonable expectation of imminent death – 2) pt in a noncognitive state with no reasonable possibility of regaining cognitive function

41. Withdrawal of Treatment Decision to discontinue treatment or medical interventions for the patient – Death is imminent & cannot be prevented

42. Persistent Vegetative State Disorder of consciousness in which patients with sever brain damage are in a state of partial arousal rather than true awareness Deals with a syndrome = uncertainty 4 wk VS = persistent – 1year VS = permanent – Not recognized as death

43. Pt not in a persistent vegetative state Guardian may not withdraw life-sustaining medical treatment if pt is not in a persistent vegetative stated

44. Removal of Life-Support Equipment There is no duty to continue the use of life- sustaining equipment after it has become futile and ineffective to do so in the opinion of a qualified medical personnel

45. Ombudsman Acts as an intermediary between the state and an individual Investigate and resolve, usually through recommendations

46. Feeding Tubes Considered Ordinary care p 151 Notify Ombudsman Tube feeding is a medical treatment and is just as intrusive as other life-sustaining measures

47. Feeding Tubes 1986 AMA changed code of ethics – Physicians may ethically withhold food, water, and medical treatment from patients in irreversible comas or persistent vegetative states with no hope of recovery even if death is not imminent

48. Do-Not-Resuscitate Orders Given by physician In event of cardiac or respiratory arrest NO resuscitation measures should be used to revive the patient

49. Do-Not-Resuscitate Orders “Heroic: rescue methods no longer in the best interest of a patient Appointed decision maker can make decision Written & signed consent

50. Do-Not-Resuscitate Orders Payne v. Marion General Hospital – Payne could communicate prior – Physician determined Payne to be incompetent – No advance directives – Relative gave DNR order

51. Advanced Directives Comes in the form of “living will” or “durable power of attorney” Can appoint an agent State in advance what medical care is desired

52. Advanced Directives Patients have a right to make decisions about their health care with their physician You still have a right even if incapacitated Advance directives allow you to make your wishes known

53. Advanced Directives Should be requested on admission If no- then hospital should provide info and opportunity to create one It is a guideline for caregivers describing your wishes

54. Advanced Directives Copy is kept in patient record Documentation in the patient record should re-highlight immediate care – Help adhere to advance directive

55. Advanced Directives Can create a new directive at any time Continual education regarding content of directive Patient should be periodically given the opportunity to make changes

56. Living Will Legal document Describes treatments individuals wish or do not wish to receive – If incapacitated and unable to communicate

57. Living Will Withholding and withdrawing life- supporting treatment – Nutrition & hydration Provides legally valid instructions about treatment – Protects patients and providers

58. Living Will Signed and dated by two witnesses not blood relatives or beneficiaries of property Discussed with physician Signed copy placed in chart Copy given to agent/proxy

59. Living Will Update regularly – Your views can change Becomes effective when – In a terminal condition, permanently unconscious, or suffering irreversible brain damage – http://www.youtube.com/watch?v=5hGWKEM7l8 s http://www.youtube.com/watch?v=5hGWKEM7l8 s

60. Durable Power of Attorney Legal device permits you to given another person the authority to act on your behalf Attorney – in – Fact – Handle banking, real estate affairs, incur expenses, pay bills, wide variety of legal affairs – Specific Period of Time

61. Durable Power of Attorney May continue indefinitely Limited by the competency of the principal General in scope – wide range of situations Each state has a durable power of attorney statute

62. Durable Power of Attorney Attorney should draw up In Health care – durable power of attorney for health care is a legal instrument that designates and grants authority to an agent

63. Durable Power of Attorney The agent when the attending physician certifies in writing that the “principle” is incompetent Can limit agents decision-making authority

64. Decision Makers Surrogate Decision Making Substituted judgment Guardianship Health Care Proxy

65. Surrogate Decision Making An agent who acts on behalf of a patient who lacks the capacity to participate in a particular decision – Limited to specific instructions in the proxy document – Base decision on patients moral and religious beliefs

66. Substituted judgment Form of surrogate decision making Agent attempts to establish what decision the patient would have made Taking into account patient’s beliefs & values http://www.youtube.com/watch?v=IytNBm8 WA1c http://www.youtube.com/watch?v=IytNBm8 WA1c

67. Guardianship Court declares a person incompetent Court appoints a guardian – Financial, living, medical

68. Health Care Proxy An individual appoints another individual to make health care decisions for them in the case that they are unable to – Be made aware of patients wishes – Differs from living will – do not have to have everything mapped out

69. Health Care Proxy Consent through durable power of attorney Oral declaration- pt declared terminally ill State determines length of effectiveness