Please complete the following REVIEW QUESTIONS

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CHAPTER 18

End-of-Life Issues

When we finally know we are dying,

And all other sentient beings are dying with us,

We start to have a burning,

almost heart-breaking sense

of the fragility and preciousness of each moment and each being,

and from this can grow

a deep, clear, limitless compassion for all beings.

—Sogyal Rinpoche

Learning Objectives (1 of 2)

Discuss the human struggle to survive and the right to autonomous decision making.

Describe how patient autonomy has been impacted by case law and legislative enactments.

Discuss the following concepts: preservation of life with limits, euthanasia, advance directives, futility of treatment, withholding and withdrawal of treatment, and do-not-resuscitate orders.

Learning Objectives (2 of 2)

Explain end-of-life issues as they relate to autopsy, organ donations, research, experimentation, and clinical trials.

Describe how human genetics and stem cell research can have an impact on end-of-life issues.

Dreams of Immortality

Human struggle to survive

Desire to prevent and cure illness

Advances in medicine and power to prolong life

Ethical and legal issues

Involving entire life span

From right to be born to right to die

Patient Autonomy

Right to make one’s own decisions

Patient has the right to accept or refuse care even if it is beneficial to saving his or her life.

Autonomy may be inapplicable in certain cases.

Affected by one’s disabilities, mental status, maturity, or incapacity to make decisions

No right is held more sacred, or is more carefully guarded, by the common law, than the right of every individual to the possession and control of his own person, free from all restraint or interference of others, unless by clear and unquestioned authority of law.

—Union Pac. Ry. Co. v. Botsford (1891)

Every human being of adult years and sound mind has a right to determine what shall be done with his own body and a surgeon who performs an operation without his patient’s consent commits an assault, for which he is liable in damages, except in cases of emergency where the patient is unconscious and where it is necessary to operate before consent can be obtained.

—Schloendorff v. Society of New York Hospital (1914)

Why Courts Get Involved: End-of-Life Issues

Family members disagree as to the incompetent’s wishes.

Physicians disagree on the prognosis.

A patient’s wishes are unknown because he or she has always been incompetent.

Evidence exists of wrongful motives or malpractice.

In re Quinlan (1976)

Constitutional right to privacy protects patient’s right to self-determination.

A state’s interest does not justify interference with one’s right to refuse treatment.

In re Storar (1981)

Every human being of adult years and sound mind has the right to determine what shall be done with his or her own body.

Superintendent of Belchertown State School v. Saikewicz (1977)

Saikewicz allowed to refuse treatment

Questions of life and death with regard to an incompetent should be the responsibility of the courts.

Court took a “dim view of any attempt to shift ultimate decision-making responsibility away from duly established courts of proper jurisdiction to any committee, panel, or group, ad hoc or permanent.”

In re Dinnerstein (1978)

“No code” orders are valid to prevent the use of artificial resuscitative measures on incompetent terminally ill patients.

In re Spring (1980)

Patient’s mental impairment and his or her medical prognosis with or without treatment must be considered prior to seeking judicial approval to withdraw or withhold treatment from an incompetent patient.

John F. Kennedy Memorial Hospital v. Bludworth (1981)

The Florida Supreme Court took the lead and accepted the living will as persuasive evidence of an incompetent’s wishes.

The Court allowed an incompetent patient’s wife to act as his guardian, and in accordance with the terms of a living will he executed in 1975, she could substitute her judgment for that of her husband.

Satz v. Perlmutter (1978)

Court required attending physician to certify patient was in a permanent vegetative state.

No reasonable chance for recovery

Before family member or guardian could request termination of extraordinary means of medical treatment

Constitutional Right to Refuse Care

The Supreme Court analyzed the issues presented in the Cruzan case in terms of a Fourteenth Amendment liberty interest.

A competent person has a constitutionally protected right grounded in the due-process clause to refuse life-saving hydration and nutrition.

Legislative Response

Chief Justice Dore of the Washington Supreme Court voiced his opinion that a legislative response to right-to-die issues could be better addressed by the legislature.

Patient Self-Determination Act of 1990

Enacted to ensure that patients are informed of their rights to execute advance directives and accept or refuse medical care

Patient Self-Determination Act of 1990

Enacted to ensure patients are informed of rights to execute advance directives and accept or refuse medical care.

Each state is required under PSDA to provide a description of the law regarding advance directives to providers.

Whether based on state statutes or judicial decisions

Providers must ensure written policies and procedures regarding advance directives are established.

Defining Death: Brain Death Criteria

Black’s law: “irreversible cessation of all brain functions including the brain stem”

Harvard Ad Hoc Committee: Brain Death Criteria (1968)

Patient shows total unawareness to external stimuli and unresponsiveness to painful stimuli.

No movements or breathing.

All spontaneous muscular movement, spontaneous respiration, and response to stimuli are absent.

No reflexes.

Fixed, dilated pupils.

No eye movement even when hit or turned, or when ice water is placed in the ear.

No response to noxious stimuli.

No tendon reflexes.

American Medical Association (1974)

Committee of the Harvard Medical School to Examine the Definition of Brain Death

Death occurs when there is “irreversible cessation of all brain functions, including the brain stem.”

New York Court of Appeals

Evidence of a patient’s intention to reject prolongation of life by artificial means

Persistent statements regarding individual’s beliefs

Desirability of the commitment to those beliefs

Seriousness with which such statements were made

Inferences that may be drawn from surrounding circumstances

—In re Westchester County Medical Center ex rel. O’Connor

Futility of Treatment

Physician recognizes effect of treatment will be of no benefit to the patient.

Morally, a physician has a duty to inform the patient when there is little likelihood of success.

Determination as to futility of medical care is a scientific decision.

Do-Not-Resuscitate Orders

Do-not-resuscitate (DNR) orders written by a physician indicate that in the event of cardiac or respiratory arrest no resuscitative measures should be used to revive the patient.

Competent patients make their own DNR decisions.

Withholding and Withdrawal of Treatment (1 of 2)

Withholding of treatment

Decision not to initiate treatment or medical intervention for the patient

Withdrawal of treatment

Decision to discontinue treatment or medical interventions for the patient when death is imminent and cannot be prevented by available treatment

Withholding and Withdrawal of Treatment (2 of 2)

Considerations

Patient is in a terminal condition and there is a reasonable expectation of imminent death of the patient.

Patient is in a noncognitive state with no reasonable possibility of regaining cognitive function.

Restoration of cardiac function will last for brief period.

Euthanasia (1 of 2)

Mercy killing

Examples: Hopelessly ill, injured, incapacitation

Active euthanasia

Intentional commission of an act

Administering the patient with a lethal drug

Passive euthanasia

Withholding or withdrawing life-saving treatment (e.g., removal of a respirator)

Euthanasia (2 of 2)

Voluntary euthanasia

Occurs when suffering incurable patient makes decision to die

Involuntary euthanasia

Occurs when a person other than incurable makes decision to terminate life of an incompetent or a nonconsenting competent person’s life

Euthanasia: Ramifications

Why

Why not

How

Who

Where

When

Euthanasia: Issues

If lawful

Long-term ramifications

What about abortion?

Right to die

Civil wrong

Negligence

Criminal offense

Voluntary

Involuntary

Physician-Assisted Suicide

Michigan and assisted suicide

Oregon’s Death with Dignity Act of 1994

U.S. Supreme Court

Prohibition of assisted suicide ruled constitutional

Assisted suicide law ruled constitutional

States legislate assisted suicide

California

D.C.

Oregon

Montana

Washington

Vermont

Advance Directives

Instructions specifying what actions should be taken in event the individual becomes incapacitated and can no longer make healthcare decisions due to incapacity

Obligation to make preferences known

Patients have an obligation to make care preferences known.

Uncertainty as to patient’s desires should be resolved in favor of preserving life.

Advance Directives: Living Will

Instrument or 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

Dying without a living will

Living Will Declaration Upheld

Advance Directives: Healthcare Proxy

Legal document that allows a person to appoint a healthcare agent to make treatment decisions in the event he or she becomes incapacitated and is unable to make decisions for himself or herself

Advance Directives: Durable Power of Attorney

Legal device that permits one individual, known as the “principal,” to give to another person, called the “attorney-in-fact,” the authority to act on his or her behalf

Advance Directives: Surrogate Decision Making

Agent who acts on behalf of a patient who lacks the capacity to participate in a particular decision

Substituted judgment

Form of surrogate decision making where surrogate attempts to establish what decision the patient would have made if that patient were competent to do so

Advance Directives: Guardianship

Legal mechanism by which the court declares a person incompetent and appoints a guardian

Autopsy (1 of 2)

Autopsy consent statutes

Authorization by decedent

Authorization by other than decedent

Autopsy (2 of 2)

Scope and extent of consent

Fraudulently obtained consent

Unclaimed dead bodies

Organ Donation and Transplantation (1 of 2)

Federal regulations require hospitals to have, and implement, written protocols regarding the organization’s organ procurement.

Regulations impose notification duties concerning informing families of potential donors.

Discretion and sensitivity should be used in dealing with families.

Organ Donation and Transplantation (2 of 2)

Educating hospital staff on variety of issues involved with donation matters, in order to facilitate timely donation and transplantation

Who lives? Who dies? Who decides?

Determination of death

Uniform Anatomical Gift Act

Failure to obtain consent

Research, Experimentation, and Clinical Trials (1 of 2)

Institutional review board

Informed consent

Research subject’s bill of rights

Failure to obtain informed consent

Duty to warn

Research, Experimentation, and Clinical Trials (2 of 2)

Patents delay research

Nursing facilities

Patient understood risks

Human Genetics

Describes the study of inheritance as it occurs in human beings

Genetic markers

DNA sequences with a known location on a chromosome that can be used to identify specific cells and diseases, as well as individuals and species

Genetic Information Nondiscrimination Act (2008)

Prohibits discrimination on the basis of genetic information with respect to the availability of health insurance and employment

Stem Cell Research

Embryonic stem cells are used to create organs and various body tissues.

Opponents argue that use of stem cells is a slippery slope to reproductive cloning and fundamentally devalues the worth of a human being.

Medical researchers argue it is necessary to pursue embryonic stem cell research because the resultant technologies could have significant medical potential.

Review Questions (1 of 2)

Describe how patient autonomy in making healthcare decisions has been impacted by case law and legislative enactments.

Discuss the following concepts: euthanasia, advance directives, futility of treatment, withholding and withdrawal of treatment, and do-not-resuscitate orders.

Explain end-of-life issues as they relate to autopsy, organ donations, research experimentation, and clinical trials.

Review Questions (2 of 2)

Describe how human genetics and stem cell research can have an impact on end-of-life issues.

Discuss the importance of genetic markers.

Explain the reason the Genetic Information Nondiscrimination Act was enacted.

Please complete the following REVIEW QUESTIONS

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