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Chapter 15

End-of-Life Issues

LEARNING OBJECTIVES

  • 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 – II

  • Discuss the purpose of an ethics committee and its consultative role in the delivery of patient care.
  • 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 & cure illness
  • Advances in medicine & power to prolong life
  • Process of dying can be prolonged
  • Ethical & legal issues have increased
  • involving entire life span, from right to be born to right to die

Scope of Ethical Issues

  • Entire Life Span
  • The Right to be Born
  • The Right to Die, &
  • Everything in between, e.g.,
  • to choose treatment
  • to refuse treatment for oneself
  • to refuse treatment for another
  • to limit the suffering one would endure

Ethical Dilemmas Arise

When values,

rights,

duties

& loyalties conflict.

Autonomy

  • Right of a person to make one’s own decisions.
  • Patient has 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 capacity to make decisions.

Quinlan court
Relying on: Roe v. Wade

  • Announced the constitutional right to privacy protects a patient’s right to self-determination.
  • State’s interest did not justify interference with her right to refuse treatment.
  • Quinlan’s father was appointed her legal guardian

Cruzan Case

  • Supreme Court held that right-to-die should be decided pursuant to state law, subject to a due-process liberty interest, and in keeping with state constitutional law.
  • Cruzans returned to Missouri probate court:
  • Judge Charles Teel authorized physicians to remove the feeding tubes from Nancy.
  • testimony presented demonstrated clear & convincing evidence Nancy would not have wanted to live in a persistent vegetative state.

Legislative Response: Patient Self-Determination Act of 1990

  • Requires healthcare organizations to explain to patients their legal right to direct their own care
  • Right to refuse medical treatment
  • Right to formulate advance directives
  • Right to appoint surrogate decision-maker
  • Federal reimbursement requires compliance with Act

Preservation of Life

  • Medical ethics does not require patient’s life be preserved at all cost under all circumstances.
  • Ethical integrity
  • of a profession is not compromised by a patient’s decision to forego medical care.
  • Right to body integrity.

Euthanasia

  • Mercy killing of hopelessly ill, injured or incapacitated
  • Active
  • intentional commission of an act, such as giving patient lethal drug
  • Passive
  • occurs when life-saving treatment (such as a respirator) is withdrawn or withheld

Physician-Assisted Suicide

  • Oregon’s Death with Dignity Act of 1994
  • physician-assisted suicide became a legal medical option for the terminally ill residents
  • U.S. Supreme Court, in two unanimous & separate decisions, ruled
  • laws in Washington & New York prohibiting assisted suicide are constitutional
  • yet U.S. Supreme Court also ruled that states can allow doctors to assist in suicide of their terminally ill patients.


Advance Directives – I

  • Making Preferences Known
  • Obligation to make medical preferences known to treating physician.
  • Any glimmer of uncertainty as to a patient's desires in an emergency situation should be resolved in favor of preserving life.

Advance Directives – II

  • Living Will
  • Health Care Proxy
  • Determining Incapacity
  • Agent’s Rights
  • Durable Power of Attorney
  • Guardianship
  • Substituted Judgment

Futility of Treatment

  • Physician recognizes effect of treatment will be of no benefit to the patient.
  • Morally, a physician has a duty to inform patient when there is little likelihood of success.
  • Determination as to futility of medical care is a scientific decision.

Withholding & Withdrawing Treatment – I

  • 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.

Withholding & Withdrawing
Treatment - II

  • When
  • Patient in a terminal condition & there is reasonable expectation of imminent death.
  • Patient a non-cognitive state with no reasonable possibility of regaining cognitive function.
  • Restoration of cardiac function will last but for a brief period.

DNR Orders

  • DNR orders written by a physician, indicate that in event of cardiac or respiratory arrest, no resuscitative measures should be used to revive patient.

Ethics Committee

  • Committee offering objective counsel when facing difficult health care issues & decisions resource to patients, families, & staff.
  • Includes wide range of community leaders.
  • Analyzes ethical dilemmas, advise & educate health care providers, patients, & families.
  • Assists patients & family in coming to consensus with options that best meet patient's care needs.

Ethics Committee Function

  • Policy & procedure development
  • Educational role
  • Consultative role
  • Political Advocacy

Autopsy

  • Postmortem examinations to determine cause of death.
  • Add to medical knowledge.
  • Necessary for criminal activity or suspicious deaths.
  • Deaths during surgery are reportable.
  • Consent required.

Organ Donations – I

  • Federal regulations
  • hospitals to have, & implement, written protocols regarding organ procurement.
  • notification duties concerning informing families of potential donors.
  • Discretion & sensitivity in dealing with families.

Organ Donations – II

  • Education
  • facilitate timely donation & transplantation
  • Uniform Anatomical Gift Act
  • allows a person to make a decision to donate organs at the time of death and allows potential donors.

Organ Donations – III

  • Millions of people suffer from kidney disease, but in 2007 there were just 64,606 kidney-transplant operations in the entire world. In the U.S. alone, 83,000 people wait on the official kidney-transplant list. But just 16,500 people received a kidney transplant in 2008, while almost 5,000 died waiting for one.

—Alex Tabarrok, The Wall Street Journal, January 8, 2010

Research, Experimentation
& Clinical Trials

  • Combination of federal & state regulations
  • Office of Research Integrity
  • Institutional Review Board
  • Informed Consent
  • Duty to Warn
  • Risks, benefits, alternatives
  • Food & Drug Administration

Organ Human Genetics – I

  • Study of inheritance as it occurs in human beings, includes stem cell research, clinical genetics (e.g., genetic disease markers) & molecular genetics.
  • Genetic markers are genes or DNA sequences with a known location on a chromosome that can be used to
  • identify specific cells & diseases
  • individuals & species

Organ Human Genetics – II

  • Genetic Information Nondiscrimination Act of 2008 prohibits
  • discrimination on the basis of genetic information with respect to the availability of health insurance & employment
  • employers from using an individual’s genetic information when making hiring, firing, job placement, or promotion decisions

STEM CELL RESEARCH

  • Use of embryonic stem cells to create organs and various body tissues.
  • highly controversial, involving religious beliefs and fears as to how far scientists might go in their attempt to create, e.g., another human being.

When We Finally Know

REVIEW QUESTIONS – I

Discuss how one caregiver’s beliefs can be in conflict with another when making end-of-life decisions. Consider topics discussed on morality, virtues, situational ethics, autonomy, and medical paternalism when framing your answer.

Discuss the ever-expanding role of ethics committees, including internal operational issues & external influences that affect internal operations.

What are the differences between allowing a patient to die and physician-assisted suicide?

REVIEW QUESTIONS – II

Examine the statement: "The inherent risk is that society's faith in doctors as healers would become subverted if doctors participate in physician-assisted suicide.“

Constitutionally, what gives patients the right to self-determination?

Explain why you think the Schiavo case is an example of legislating morality.