Ethics: Life and Death Issues

Chapter 8: Life and Death Issues

• Ethics is reverence for life. Dying is a facet of living and part of the natural progression.

Chapter Objectives

• The chapter will cover:
• Issues surrounding end-of-life care
• The importance of advance directives
• Legal and ethical options for patients and families making decisions about end-of-life care
• Issues surrounding fertility options
• Legal and ethical issues surrounding the beginning of life

Key Terms

• Abortion
• Active euthanasia
• Artificial insemination
• Assisted reproduction
• Beneficence
• Conscience clause
• Curative care
• Euthanasia
• Healthcare proxy
• Hospice
• In vitro fertilization
• Living will
• Medical power of attorney
• Palliative care
• Passive euthanasia
• Persistent vegetative state
• Surrogacy
• Uniform Anatomical Gift Act

Ethical Issues Related to Dying

• An 87-year-old widow named Evelyn checked into the emergency room complaining of abdominal pain.
• She was confused and unable to make decisions for herself.
• She has had two surgeries related to diverticulitis and abdominal cancer in the past 3 years.
• She also suffers from severe back and leg pain, which has recently been diagnosed as sciatic nerve pain.
• Evelyn has two advance directives on file: a living will and a designation of her only son as a healthcare proxy.
• Evelyn and her son should meet with the hospital's ethics committee to discuss options.
• Curative care is any care given in an effort to cure or reduce a medical problem.
• At some point, medical treatments to “cure” Evelyn will likely cause more pain and suffering, rather than positive outcomes.
• Treatment is usually switched to palliative care which aims at reducing pain and suffering as a person nears the end of life.
• Patients may receive palliative care from their family doctor, or a hospice provider.
• Hospice facilities provide palliative care.
• Curative care is no longer provided once a patient receives services from a hospice provider
• Only services offered alleviate pain and suffering and not prolong life.

Advance Directives

• Advance directives are legally binding statements to help a person make wishes known about end-of-life issues.
• There are four types of advance directives:
• Do not resuscitate (DNR) orders
• Living wills
• Power of attorney or healthcare proxy designations
• Uniform Anatomical Gift Act, otherwise known as organ donation

DNR Order

• A DNR order informs healthcare professionals that a patient does not want extreme measures taken to save their life during cardiac arrest.
• These measures include cardiopulmonary resuscitation (CPR) and defibrillation.
• DNR orders are recommended for patients who have a terminal illness with a prognosis of 6 months or less to live and prefer to die naturally.
• An adult must be competent to request a DNR order.
• A power of attorney or healthcare proxy might request the DNR order if an adult is not considered competent or unable to express their wishes.
• Ethical complications occur when hospital personnel are not aware that the patient has a DNR order.
• Any attempts at resuscitation must be stopped once the DNR order is discovered.
• Continuing with resuscitation efforts would violate legal documents as well as the patient's personal wishes.

Living Will

• A living will is a legal document that indicates whether a patient wants to be placed on life-prolonging machines should they be unable to communicate personal preferences.
• It must be notarized or signed by two witnesses to be considered legal.
• Regulations on living wills vary from state to state.
• If a patient states in a living will that they do not want life support, then the patient cannot legally be placed on machines.
• If patients are on life support before the living will is discovered, then the medical team must start the process of withdrawing life support.
• Withdrawing treatment means discontinuing it once it has already been started, where as withholding treatment means not starting it because the patient's wishes are known.
• Healthcare professionals may feel that withdrawing life support would betray their code of ethics, or beneficence.
• Without a living will, a power of attorney or healthcare proxy will need to work with an ethics committee and the attending physician to determine the appropriate course of action.

Terri Schiavo Case

• In the landmark case of Terri Schiavo, the ethical dilemma of withdrawing life support was put on trial.
• Terri suffered irreversible brain damage due to self-inflicted malnutrition.
• Her husband's court-appointed doctors determined she would most likely not recover and her life support should be discontinued after 15 years.
• Terri did not have a living will, so the courts did not have a legal document on which to base a decision.
• Terri's parents argued that life support and therapy efforts should be continued.
• It resulted in the removal, re-insertion, and then final removal of the feeding tube.
• An autopsy showed that brain damage was much more severe than they had suspected, and recovery would most likely not have occurred.
• The decision to withdraw life support can be fraught with legal and ethical complications without a living will.

Power of Attorney and Healthcare Proxy

• When competent adults are not able to make decisions themselves, they might rely on a power of attorney and/or a healthcare proxy to make decisions for them.
• A power of attorney is a written document that legally allows someone to make decisions on your behalf: financial or health related.
• A healthcare proxy is a person designated to make health decisions on your behalf.
• A healthcare proxy designation is not the same as a financial power of attorney, who handles monetary and estate decisions.
• The same person can be both a financial power of attorney and a healthcare proxy, but some choose to have different individuals handle each role.

Organ Donation

• As of March 13, 2012, approximately 122,000 people in the United States were waiting for a lifesaving second chance through an organ transplant.
• The list of those waiting continues to grow at a faster pace than donation.
• Preventative must include lifestyle changes in the United States to be healthier so that fewer people need transplants.
• The plague of hepatitis C that must be addressed and a solution found.

Uniform Anatomical Gift Act

• The Uniform Anatomical Gift Act, passed in 1968, allows anyone 18 years of age or older to donate body parts for the purpose of transplantation after their passing.
• It also allows next of kin to give permission regarding donation of body parts.
• To help simplify and organize the donation of organs, a second law (National Organ Transplant Act) was passed in 1984.
• The act created a network for registering and matching organ donor recipients.
• Many states have written laws that allow or require all individuals with a driver's license to designate their organ donor status
• An organ donor must have approval from a parent or guardian until 18 years of age.

Making End-of-Life Decisions

• Historically, doctors only provided curative care until the patient requested that treatment stop or simply passed away.
• When life support systems were first introduced, they were seen as a possible new way to keep patients alive indefinitely.

Karen Ann Quinlan Case

• At 21 years of age, Karen Ann Quinlan suffered severe brain damage after a drug and alcohol overdose.
• She was determined to be in a persistent vegetative state, without enough cognitive function to make voluntary movements and be aware of her surroundings.
• Karen Ann was placed on life support, which was relatively new technology at the time.
• After several months, Karen Ann's muscles began to atrophy.
• They requested that she be removed from the ventilator that was keeping her alive stating her quality of life was severly diminished.
• The hospital refused because they were certain that she would die if taken off of the ventilator and feared litigation from the county prosecutors, who threatened to charge them with homicide.
• The family took the case to the New Jersey Supreme Court, who ruled in favor of them based on the difference between ordinary and extraordinary.
• The ruling stated the hospital had an obligation to provide ordinary, but not extraordinary, means and that life support would be considered extraordinary.
• Karen Ann continued to breathe on her own after the ventilator was removed and finally died of natural causes 9 years later.

Nancy Cruzan Case

• In 1983, Nancy Cruzan was thrown from a vehicle during an accident and landed facedown in a ditch filled with water.
• She remained in a coma for several weeks and was finally determined to be in a persistent vegetative state
• A feeding tube was inserted for long-term care and her husband and family waited 7 years for any signs of recovery.
• the hospital argued that Nancy Cruzan was breathing and her heart was pumping without medical intervention, so they would not remove the feeding tube without a court order.
• The case went to the Missouri Supreme Court who ruled that clear and convincing evidence of a patient's wishes are needed before a life-sustaining mechanism can be withdrawn.
• Nancy had verbally expressed her wishes to not remain alive on life support, but there was no legal document to provide evidence.
• After the court's decision, the family members were able to gather more proof of Nancy's wishes and eventually the feeding tube was removed. Nancy died 11 days after the feeding tube was removed.

Euthanasia

• The Nancy Cruzan case tested a new issue related to patient rights and state governments.
• This includes the right to choose when their life will end.
• Two states (Oregon and Washington) have already passed laws allowing terminally ill patients to obtain lethal doses of medication, and several states are considering this opinion
• Oregon was the first state to pass a law related to physician-assisted death.
• Euthanasia is a term derived from Greek, meaning "the good death.”
• There are two types of euthanasia: passive and active.
• Passive euthanasia is allowing a patient to die naturally by withholding treatment, including food and water.
• Physician-assisted death, on the other hand, is considered a form of active euthanasia which is considered the intentional killing of a patient by non-natural means.

Jack Kevorkian Case

• Jack Kevorkian was a doctor and scientist fascinated with the dying process.
• Reportedly assisted 130 suicides over the course of 8 years.
• Invented a machine that allowed patients to self-administer lethal doses of medication in order to end their lives.
• The state of Michigan suspended his medical license and passed a law making assisted suicide illegal.
• Kevorkian was convicted of second-degree murder in 1999.
• He was shown administering lethal drugs to a patient, which resulted in his death in a video.
• His release was contingent on a promise not to assist with any more suicides.
• Dr. Kevorkian's actions were controversial, and they opened the door for state lawmakers to consider the rights of dying patients.

Death With Dignity Act

• Oregon's Death With Dignity Act allows terminally ill patients in Oregon to self-administer a lethal dose of medication that is legally prescribed by a doctor.
• Patients must have a diagnosis of a terminal illness that will cause death within 6 months and be free of any mental illness, including depression.
• Healthcare professionals in long-term care or hospice facilities are most likely to encounter patients making end-of-life decisions.
• Therapists should know and understand the patient's wishes regarding quality of life when considering treatment options.
• A speech therapist, for example, might be called in to evaluate a patient for feeding tube placement/ they shoud consider the quality of life a patient near the end of life would have with a feeding tube in place

Ethical Issues Related to Life

• Assisted reproduction refers to artificial or semi-artificial methods of achieving pregnancy; artificial insemination, in vitro fertilization, and surrogacy.
• During artificial insemination, the woman takes drugs to increase egg production, and sperm is then implanted with a device to achieve pregnancy.
• In vitro fertilization involves a woman taking drugs to stimulate egg production, and then reinserted into the uterus.
• Generally, several eggs are used in the hope that at least one of them will develop into a surviving embryo.
• Surrogacy involves having another woman carry the baby from conception to delivery.

Ethical Issues

• Assisted reproduction options are used by couples who have been unable to conceive or carry a baby to term, or by same-sex couples who wish to have children with a genetic link to one of the parents.
• Fertility treatments generally come at a high price and are not always covered by insurance policies which reduces options for couples with limited income who are unable to conceive naturally.
• In vitro fertilization creates more ethical issues when embryos are created and stored.
• Pro-life activists argue that destroying embryos is destroying life.
• The long-term impact on infants and mothers are also not known at this time since uterus transplants are very new.

Nadya Suleman Case

• Nadya Suleman gave birth to octuplets in 2009: They were conceived after 12 embryos were implanted during an in vitro fertilization procedure.
• While carrying octuplets to term is quite controversial, Nadya's situation was even more complicated because she was already a single mother to six children.
• In addition, the implantation of 12 embryos was considered extreme, and as a result the Medical Board of California chose to revoke the license of the doctor involved.

Rights of the Mother vs Child

• Historically, there have been many ethical and legal issues surrounding the rights of an unborn child versus the rights of the mother.
• The decision was made to have an early delivery for abagail and tony.

Angela Carder Case

• After several years of battling bone cancer, 27-year-old Angela Carder became pregnant where a tumor was found in Angela's lung.
• At the beginning of Angela's pregnancy, she had clearly expressed her wish to have cancer treated if it resurfaced
• Surgery was not an option, leaving only chemotherapy and radiation in an effort to prolong Angela's life
• Angela’s parents and doctors supported her decision to delay delivery and start treatments to fight the tumor
• the hospital required a court order to obey her wishes as Angela knew that she would most likely not survive the surgery/ the fetus died within 2 hours

Conscience Clause

• The conscience clause, a federal regulatory law, protects healthcare professionals from discrimination if they refuse to participate in sterilization procedures or abortions
• Opponents of the conscience clause state that healthcare professionals should not be able to opt out of normal job duties simply because they find them offensive.
• Ethically, it is important for healthcare professionals to research their job duties carefully before accepting a job
• Legally, a healthcare professional must tell an employer that he or she wishes to utilize the conscience clause at the time of hire.
• Historically, the rights of a mother are placed before the rights of a fetus which includes the right to have an abortion.

Abortion

• An abortion is the termination of a pregnancy by removing the fetus from the uterus before it has a chance to become viable.
• In the landmark case of Roe v. Wade, the U.S. Supreme Court ruled that a woman's right to privacy extends to fertility decisions: the states were given the right to regulate abortion
• Individuals in favor of abortion usually argue that life does not begin until the time of birth, while individuals against abortion argue that life begins at conception. It is important to remain within the appropri- ate scope of practice and only make recommendations that align with your training an