Death and Decisions Regarding Life-Sustaining Treatment

1. Death and Decisions Regarding Life-Sustaining Treatment

2. Definition and Determination of Death • How do you define death? • How do you determine death?

3. “Brain-Dead” • Entire brain has irreversibly ceased functioning • Irreversible unconscious • Heartbeat and respiration maintained by machines

4. “Persistent Vegetative State” (PVS) • Brain-stem function is sufficient to sustain respiration and heartbeat • Brain damage is so severe that consciousness has been irreversible lost

5. Question • Are the patients in each of these groups alive or dead? • What is the morally appropriate treatment for these type of patients?

6. Traditional Definition of Death • Permanent loss of respiration and heartbeat

7. Implications • What are the implications of brain dead patients being dead patients? • Vital organs can be taken • If artificial means keeping the patient alive are turned off That is not the cause of death

8. Uniformed Determination of Death Act • 1. Irreversible cessation of circulatory and respiratory function • 2. Irreversible cessation of all functions of the entire brain, including the brainstem

9. The whole-brain standard has widespread public acceptance in the United States • But some challenges still remain

10. Competent Adults and the Refusal of Life-Sustaining Treatment

11. Life-Sustaining Treatment • Non-Palliative Care • Mechanical respiration • Kidney dialysis • Surgery • Antibiotics • Etc.

12. Palliative Care • Generally refers to any care that alleviates symptoms, • whether or not there is hope of a cure by other means • Pain management • Food and Water

13. 3 Important Differences • 1. Life-sustaining treatment would return to a state of health • 2. Life-sustaining treatment would continue a very poor quality of life • 3. Life-sustaining treatment would just prolong the dying process

14. 1. Life-sustaining treatment would return to a state of health • Refusals rare • Exception: Religious Cases

15. 2. Life-sustaining treatment would continue a very poor quality of life • Law now recognizes the right of competent adult to refuse treatment in these cases • Have to be careful about influence of depression, quick decisions, etc.

16. 3. Life-sustaining treatment would just prolong the dying process • Very common • Legally acceptable

17. DNR Orders and Medical Futility • DNR = Do not resuscitate • CPR = Cardiopulmonary resuscitation • Medical Futility??

18. Medical Futile • When resuscitation would almost certainly not be successful • This judgment falls upon physician’s expertise

19. Do Not Resuscitate • Under what circumstances should DNR be followed?

20. 1. Quality of life judgments must be made by patients or patient’s family if incompetent

21. 2. Inappropriate for physician to write a DNR order without permission of patient or family

22. 3. It is morally acceptable for physician to order DNR order when if would be medically futile

23. “Everything must be done” • Physician’s decision not to resuscitate becomes problematic when the family insists that • “everything must be done” • Under these circumstances is physician justified is refusing treatment

24. Legality • Physician must be ready to justify his/her judgment in a court of law

25. Advanced Directives • Legal document that specifies what a patient wants done or not done regarding life sustaining treatment in the event he /she is incapacitated

26. Living Will • Also called an • Instructive Directive • Specifies what you want done regarding life sustaining treatment if you are incapacitated

27. Durable Power of Attorney • In addition to a living will, this gives someone else the power to make decisions for unforeseen circumstances that a living will might not address

28. Surrogate Decision Maker • If no living will or durable power of attorney has been executed, then someone must be identified to make life sustaining decisions Usually family member or close friend

29. How should decisions be made regarding life sustaining treatment?

30. Substitute-Judgment Standard • When a situation arises that has not been addressed in a living will • The surrogate decision maker is expected to make a decision that would be in keeping with the patient’s desires, preferences, wishes

31. Best-Interest Standard • If no reliable basis exists to infer what the patient would have chosen, • then the surrogate decision maker is expected to apply the “best-interest” standard.

32. What is in the best interest of the patient? • What would a reasonable person choose in this situation?

33. Ambiguous Concepts • Make sure all meaningful terms are defined Such as: “Meaningful quality of life”

34. Impaired Infants • Under what conditions, if any, is it morally acceptable to allow a severely impaired newborn to die? • Who should make the decision to treat or not to treat?

35. Physicians? • Parents? • Hospital Ethics Committees?

36. 3 Different Views • Quality of Life View • Hardship View • Pro-Life View

37. Quality of Life View • It is acceptable to allow a severely impaired newborn to die if and only if death would be in the infant’s best interest. • If the infant would be better off dead • Quality of life judgment

38. Hardship View View • It is morally acceptable to allow a severely impaired newborn to die if: • 1. There is no significant potential for a meaningful human existence • 2. The emotional and/or financial hardship of caring for the newborn would be a graven burden to the family

39. Pro-Life View • It is never morally acceptable to allow a severely impaired newborn to die • You must treat all newborns the same • If you would do something for a normal newborn, then do it for all newborns