End of Life: Euthanasia and DNR Orders

End of Life Dilemmas

• Presented by Dr. Lamis Nader, Assistant Professor, on March 9, 2025.

Objectives

• Define euthanasia and physician-assisted suicide.
• Classify euthanasia and explain the related ethical concerns.
• Discuss the worldwide rules and regulations governing euthanasia.
• Identify mechanical ventilation as a supportive technique in terminal illness and discuss the ethical arguments around it.
• Define medical futility and discuss the dilemma of do not resuscitate orders (DNR).

Euthanasia

• Euthanasia involves a third party, typically a physician, terminating a person's life either passively or actively.
• The term "euthanatos" is Greek for "easy death."
• The modern concept emerged in the 20th century with life-extending technologies.
• Modern medical technologies can sustain patients in situations considered worse than death, like comas or persistent vegetative states (PVS).

Persistent Vegetative State (PVS)

• PVS describes a patient who has lost higher cerebral functions, but the brainstem remains relatively intact.
• Patients exist in a vegetative state with spontaneous respiration, intact cardiac function, but require parenteral feeding.
• The condition is persistent and may last for years.
• PVS may result from traumatic or non-traumatic injuries, degenerative conditions, or developmental malformations.
• Characterized by wakefulness without awareness, sleep/wake cycles, the ability to follow objects with eyes, and involuntary expressions.
• Medico-legal importance includes preventing infection and bedsores, and providing balanced nutrition.

Types of Euthanasia

• Passive euthanasia involves withholding or stopping medical interventions.
• Active euthanasia involves taking direct action to end a person's life.
• Withholding life support is a form of passive euthanasia and is defined as intentionally ending a life through medical omission.
• Passive euthanasia is "allowing a person to die" by removing supportive treatment, where the underlying condition ends the patient's life.
• Active euthanasia requires performing some action that terminates the life of a person.
• Voluntary euthanasia involves a competent patient requesting termination of life to avoid suffering.
• Non-voluntary euthanasia occurs when a person is unable to make a choice, and someone else decides on their behalf.
• Involuntary euthanasia is when a person who wants to live is killed against their will (considered murder).

Techniques of Euthanasia

• Euthanasia is performed by an attending physician administering a fatal dose of a suitable drug at the patient's request.
• Barbiturates are most commonly used to slow brain and nervous system activity.
• Secobarbital and pentobarbital have been used alone or in combination for physician-assisted suicide or euthanasia and for animal euthanasia.

Ethical Issues Surrounding Euthanasia

• Whether terminating life at an individual's request is immoral depends on the individual's decision.
• Terminating life may be justified only if continuing to live would be more harmful than dying.
• Terminating life may be unethical due to inadequate protections for just and fair practice.
• Terminating life is unethical as it violates the moral belief that life should never be intentionally taken and and the basic human right not to be killed.

Supporters of Passive vs. Active Euthanasia

• Supporters of passive euthanasia argue physicians do not kill but rather, the disease takes the patient's life.
• Patients have right to a "death with dignity," making naturally dignified death a moral act, different from active euthanasia.
• Physician participation in active termination is controversial due to violating the physician's oath to "do no harm."

Arguments About Euthanasia

• Euthanasia advocates argue that physicians violate "do no harm" by extending the life of a suffering individual.
• The concept of "death with dignity" is popular among those who support active euthanasia.
• Prolonged death is unnatural and undignified; encouraging death with dignity supports those who want to end non-beneficial treatment.

Euthanasia and Religion

• Christians generally oppose euthanasia based on the belief that life is given by God.
• The Islamic code forbids taking one's life, emphasizing preserving life and well-being, so Islamic doctrines consider PAS and euthanasia forbidden.
• Withholding or withdrawing futile treatment may be permissible if a patient has a imminently fatal illness.
• Islamic countries do not legalize PAS or euthanasia, considering them suicide or homicide.

Euthanasia and Law

• In Europe, euthanasia is legal only in the Netherlands and Belgium under specific conditions.
• Euthanasia is only allowed if the patient is an adult in Belgium.
• In Netherlands, children aged 12-16 can undergo euthanasia with parental consent and those over 16 alone.
• Only passive euthanasia is permitted in Japan for patients in a coma for 3+ months.
• Switzerland is the only country that permits euthanasia even for foreign citizens.
• Passive euthanasia is permitted when a desire for it in advance through the country of Finland.
• As of December 2020, active euthanasia is legal in the Netherlands, Belgium, Colombia, Luxembourg, Western Australia, Spain and Canada.
• Assisted suicide is legal in Switzerland, Germany, the Australian state of Victoria, and in the U.S. states of Washington, Oregon, Colorado, Hawaii, Vermont, Maine, New Jersey, California, and the District of Columbia.

Rules and Regulations in the UAE

• New laws (2016) outright ban euthanasia or 'mercy killing', even with patient consent.
• Health legislation permits a natural death by withholding CPR or advanced cardiac life support if the patient has an incurable terminal illness.
• Three doctors must consent after treatment has failed.
• Laws prohibit withholding cardiopulmonary resuscitation against the will of the patients who clearly request CPR, even if resuscitation is of no use.
• Under these changes, doctors would not face prosecution for failing to resuscitate dying patients.

Physician Assisted Suicide

• A doctor provides a prescription for drugs that a patient could use to end their life.
• Physician-assisted suicide is only an option for conscious patients capable of making their own decisions.
• Physician-assisted suicide is the active choice by a person to end their own life with the help of a physician; it is considered assisting in murder by others.

Ethical Arguments Offered to Justify Physician Assisted Suicide

• It allows autonomy and self-empowerment of the patient.
• Shows compassion and mercy.
• Gives freedom from suffering.
• People against suicide may still object as it requires physician involvement who are taught to treat illness and extend life, going against their training.

Opioids

• It is not illegal to prescribe large doses of opioids to relieve pain, breathlessness, or other symptoms.
• Even very large doses of opioids are permitted and appropriate if the intent and doses given are titrated to the patient's needs.
• Treatment of symptoms does not constitute euthanasia.
• For patients who have been using opioids for pain, it is difficult to give such high doses that death is caused or even hastened.

Morphine

• Morphine is the most commonly used narcotic for treating pain and morphine is particularly good at relieving pain and shortness of breath.
• The fear that respiratory depression may cause doctors to under-prescribe.
• Recent research has not found narcotics to shorten life or depress respiration in dying patients - even when higher doses of narcotics are given.

Mechanical Ventilation

• Uses a machine ventilate a patient and also allows oxygenation of the blood. The machine is attached to the patient's nose or mouth.
• About 75% of dying patients experience breathlessness.
• Ventilation is may be given to patients not to extend life but instead with breathlessness, sleep in mind, experiencing less anxiety, as well as eating and drinking more comfortably.
• Mechanical ventilation is the most common life support treatment withdrawn in anticipation of death.
• Mechanical ventilation may be looked as "death-delaying" rather than "life-prolonging.
• Some patients become dependent on the ventilator.
• It could be considered a non-beneficial treatment delaying natural death which is why families or physicians decide to withdraw as treatment.

Ethical Misperception About Foregoing Ventilator Support

• Withdrawal of ventilator support is a form of patient abandonment; "Patient abandonment" when patient is not replaced.
• Withdrawal of mechanical ventilation may be mistakenly perceived as a form of abandonment.

Principal of Beneficence

• The ethical principle of beneficence requires clinicians to act to promote a patient's well-being.
• For some critically ill patients, ventilating to die in a way in accordance to a patients wishes is favored over living in ways he or she would deem to be a “state worse than death."

Clinical Parameters Suggesting Prognosis of < 1 Hour Following Ventilator Withdrawal

• pH ≤ 7.32
• Glasgow coma scale ≤ 3
• Spontaneous respiratory rate ≤ 10
• Systolic blood pressure ≤ 84 mm Hg
• PEEP > 10 cm H₂O
• Peak Inspiratory Pressure > 35 cm H₂O
• FiO2 > 70%
• Vasopressor use

Nutrition and Hydration

• These provide nutrients and water to patients who are unconscious or cannot swallow
• The main dilemma concerns people and water
• The American Medical Association does not distinguish between nutrition and hydration in general, while others argue nutrition is palliative care.
• Debate concerning nutrition and hydration centers on whether or not withholding food and water is similar to the act of killing a patient.
• Nutrition treatments may burden some dying patients. Instead of hydrating the patient, water can cause bloating and swelling.

Medical Terms Related to Life-Sustaining Treatment

• Cardiopulmonary resuscitation (CPR): Resuscitating cardiac or respiratory arrest.
• Code: Calling trained professionals to CPR
• No code: A person's signed order of their doctor stating that the patient should not get CPR, often called "Do-Not-Resuscitate."
• Irreversible coma: A coma or persistent vegetative state from which the person will not recover.
• Terminally ill: The medical state of being near death where there is no hope of cure.
• Life-sustaining treatment: Any medical procedure, drug, or technology that can keep a person alive.
• Palliative care: Specialized medical care that is focused on keeping a person free of pain and the stresses of a serious illness even with diagnosis.

Medical Futility

• Are interventions that are unlikely to produce any significant benefit for the patient, there are two different types.
• Quantitative futility, where there is exceedingly poor for benefit.
• Qualitative futility, where a very poor quality of benefit happens.

What is a do not attempt resuscitation (DNAR) order?

• (DNR) order is made when the patient is not expected to survive and states that CPR is not required.
• CPR can try to make perfusion when it will not likely work to recover due to underlying cause.

Who?

• The DNR might be assigned to some patients that might otherwise use CPR.
• Those who CPR would not help.
• Those whom it would result in permanent damage.
• Or those whose quality of life would decrease overall.

The American Heart Association(AHA)

• In 1974, the American Heart Association (AHA).
• Physician's recognize the point when CPR is not worth it.
• Known as DNR or do not rescusitate.
• Do-Not-Attempt-Rescusitaion or DNAR order has practical results in allowing patients to pass.

What about "slow codes" or "show codes"?

• Slow codes and show codes are a form of form of "symbolic" but not real help for the patients medical issues.
• These slow and show codes are not full of vigorous efforts, do not help as expected, but helps to appease the families.
• Ethically, performing slow action codes that undermine the rights of patients to involve with decisions.