NCM 108-mIDTERM

• resuscitation

• mechanical ventilation

• artificial nutrition and hydration

• terminal sedatives,

• withholding and withdrawing treatments

• euthanasia,

• physician-assisted suicide.

What are the Ethical Issues in Death and Dying?

Human Dignity

is the most fundamental of all ethical principles.

Human Dignity

It is the recognition that human beings possess a special value intrinsic to their humanity and as such are worthy of respect because they are human beings

reverence

respect

protection towards each person as a free being with a unique history.

Human dignity involves

● The first obligation that ensues from human dignity is to preserve people’s lives and to ensure their safety.

● The second is to work for the human development of every person, to recognize to them a unique personality and a participation in the community (recognition).

● The third is to be compassionate in times of difficulty and distress. Every person deserves to receive care adapted to his or her condition.

What Does Human Dignity Require?

○ In control

○ Valued

○ Confident

○ Comfortable

○ Able to make decisions for themselves

Why is Dignity Important?

So that people will feel":

1. Euthanasia and Prolongation of Life

2. Inviolability of Human Life

3. Euthanasia and Suicide

4. Dysthanasia

5. Orthothanasia

6. Administration of Drugs to the Dying

7. Advance Directives

8. DNR or End of Life Care Plan

Dignity in Death and Dying Topics

Dysthanasia

This refers to the practice of excessively prolonging the dying process through aggressive medical interventions, even when there's no realistic hope of recovery or improvement in quality of life.

Orthothanasia:

This involves allowing a natural death to occur by withholding or withdrawing life-sustaining treatments when they are no longer beneficial or desired.

Euthanasia

Is any action committed or omitted for the purpose of causing or hastening the death of a human being after birth. It is usually done for the alleged purpose of ending the person’s suffering.

Happy death

Euthanatos means

Inviolability of Human Life

Is the principle of implied protection regarding aspects of sentient life that are said to be holy, sacred, or otherwise of such value that they are not to be violated.

According to the Sanctity of Life Principle, life is of intrinsic value

According to the ____________________, life is of intrinsic value

According to the Qualified Sanctity of Life Principle, one cannot actively and intentionally hasten death; however, one can refrain from preventing natural death. Treatment can, therefore, be omitted, allowing death to occur “naturally”.

According to the ____________________, one cannot actively and intentionally hasten death; however, one can refrain from preventing natural death. Treatment can, therefore, be omitted, allowing death to occur “naturally”.

The Quality of Life Prínciple

Some human lives are not worth living. Thus, assisted suicide, voluntary euthanasia, and perhaps even non-voluntary euthanasia are permissible in some circumstances.

Permits intentional hastening of death using either acts of omission (withholding or withdrawing treatment) or commission (prescribing overdose or administering lethal injections).

Permits intentional hastening of death using either acts of __________ (withholding or withdrawing treatment) or _______________ (prescribing overdose or administering lethal injections).

Euthanasia and Suicide

It is translated literally as 'good death' or 'happy death'.

Euthanasia

The individual right to die in a painless and peaceful manner. Is the practice of intentionally ending life to eliminate pain and suffering.

Suicide

An act where a person deliberately plans and follows through on taking their own life.

Assisted Suicide

A situation where the person is going to die, needs help to kill themselves, and asks for it. A qualified medical practitioner supplies the patient with the means. The patient kills him/herself.

Mercy Killing

Often used interchangeably with euthanasia, however, the killing may be done without the patient request or consent.

PALLIATIVE CARE

Medical, emotional, and spiritual care given to a person which is terminally with the aim as reducing suffering and not curingcere

Active Euthanasia

Passive Euthanasia

Voluntary Euthanasia

Non-voluntary Euthanasia

Involuntary Euthanasia

Classification of Euthanasia

Active Euthanasia

A situation in which a physician prescribes, supplies or administers an agent that results in death. You assist the patient to die. Ex. Down Syndrome newborn, Therapeutic abortion.

Voluntary Euthanasia

Where a person makes a conscious decision to die and asks for help to do so. Conducted with consent of the patient.

Passive Euthanasia

A situation in which no extraordinary measures are undertaken to sustain life or when life sustaining treatments are withheld. Ex. NO Code or NR

Non-voluntary Euthanasia

When a person cannot make a decision or is unable to give their consent (example they're in a coma) and so someone else (e.g. a doctor or a family member) takes the decision on their behalf, that it would be in the person's best interest if their life was ended

Involuntary Euthanasia

When euthanasia is performed on a person who would be able to provide informed consent does not, either because they don't want to die, or they were not asked. (e.g. a doctor or a family member decides) It is often against the patient's will. (Murder)

1. Illness must be terminal

2. All measures have been tried

3. Patient repeatedly requests without being coerced.

4. Doctor ensures patient's judgement is not distorted

5. Procedure is carried in a meaningful physician-patient relationship

6. Other physicians are considered in the procedure

7. Documentation to assure of the previous steps

Safeguards and Guidelines for Assisted Deaths:

Orthothanasia

It is the process of the humanization of death and alleviation of pain, but it does not abusively prolong death with the implementation of futile treatment which would cause more suffering to terminal patients. (Humane and correct death).

● The person is terminally ill

● Their quality of life is severely damaged

● There is no hope of recovering from their illness They fear loss of control or of dignity

● They fear severe pain and suffering

● They dislike being dependent or a burden

Why would someone want euthanasia or assisted suicide?

Dysthanasia

The application of medical procedures intended to maintain life at all costs, even when the condition is not curable and medical procedures often prolong the patient's pain and suffering

Orthothanasia

Is death in its natural and inevitable process, respecting the person's right to die with dignity, supported by palliative care.

Dysthanasia

Slow and painful death without quality of life

Palliative sedation

is the practice of relieving distress in a terminally illness person in the last hours or days of a dying patient's life

• Anxiolytic sedatives

  • Midazolam, Lorazepam

• General Anesthetics

  • Propofol , Ketamines

• Neuroleptics

  • Haloperidol

• Barbiturates

  • Phenobarbital, Penthobarbital

Palliative sedation. The use of special drugs to relieve extreme suffering by making a patient calm, unaware, or unconscious.

○ Common Drugs Used 🙂 ?

■ Fear of being accused of assisting suicide, mercy killing, or euthanasia particularly when it is against moral beliefs.

■ Belief that certain types of suffering should be treated with terminal sedation while others should be: i.e. physical pain versus existential suffering.

■ Belief that being conscious has great value during the last days or weeks of life.

■ Terminal sedation may hasten death through immobility

Reasons for Not Using Terminal Sedation:

■ To aggressively treat suffering whether it is physical or existential suffering.

■ Remove a patient's justifiable fear of pain not to be forced to die in pain even if it means that they will be sedated to unconsciousness.

Reasons for Using Terminal Sedation:

Withholding treatment

Is the act of not instituting measures that would serve to either prolong life or delay death.

Withdrawing treatment

Is defined as the removal or discontinuation of life-sustaining/life-prolonging therapies of a treatment considered medically futile in promoting an eventual cure or control of disease or symptoms

Withdrawal or withholding treatment

Is a decision/action that allows the disease to progress on its natural course. It is not a decision/action intended to cause death

1. Patient choice

2. Burdens outweigh benefits

3. Undesirable quality of life

4. Prolonging the dying process

Common Reasons for withdrawal or withholding treatments:

Advance directive

Are legal documents that communicate a person's wishes about health care decisions in the event the person becomes incapable of making health care decisions.

1. Living Will

2. Durable Power of Attorney or Health Care Proxy

Types of Advance Directives:

18yo with sound mind, 2 witnesses, notarized)

Qualification for living will

It can only take effect if you have a terminal condition and are incapacitated or unable to communicate your preferences for care.

Living will can only take effect if,

Testator

A person who has written a will and executed a will and testament that is in effect at the time of their death.

intestate

Having died without leaving instructions about who should be given your property

Attestation

The act of witnessing the signing of a formal document

Holographic

Document (as a will or deed) entirely in the handwriting of a person whose act it purports to be

Physicians Order for Life sustaining Treatment

POLST meaning

Healthcare Power of Attorney (Durable Power of Attorney/ Healthcare Proxy)

Is an advance care directive or agreement where the principal, designate another person to have the power and authority to make healthcare decisions for the principal.

"Principal" - client,

"Agent" - person you choose to make decisions

What is a principal and agent in relation to the power of attorney

POLST

Is a document you and your doctor fill out together that outlines your wishes for end-of-life care, including CPR and feeding tubes. It's more detailed than a DR (do not resuscitate order.

● Reassure clients and families that they have the option to change their decision.

● Assess whether clients, families have accurate understanding of life-sustaining measures

● Be supportive of client's decision.

Role of Nurse in advance directive

If you have an illness that can't be cured, based on the understanding that DEATH is inevitable, palliative care makes you as comfortable as possible, by managing your pain and other distressing symptoms. It also involves psychological, social and spiritual support for you and your family or careers.

End of life care includes palliative care.

■ Have an advanced incurable illness, such as cancer, dementia or motor neuron disease are generally frail and have co-existing condition that mean they are expected to die within 12 months.

■ Have existing conditions if they are at risk of dying from a crisis in their condition

■ Have a life-threatening acute condition caused by a sudden catastrophic event, such as an accident or stroke.

When Does End of Life Care Begins?

Do not Resuscitate Order

is a document signed by a doctor at a patient's request that indicates the patient doesn't want to receive CPR. CPR, or "cardiopulmonary resuscitation,"

1. Mouth-to-mouth breathing

2. Chest compressions

3. Administration of controlled electric shocks to the heart (known as "defibrillation")

4. Breathing tube insertion (known as "intubation"

DNR order may involve several potentially life-saving emergency procedures including:

Nowadays according to JAHCO, DNR must be appropriately documented on the chart or on a special form called advanced directives, and an informed consent should be obtained, along with a witness, who might be a nurse taking that role, or one of the family members

T/F: DNR can be given verbally

1. Treat people compassionately

2. Listen to people

3. Communicate clearly and sensitively

4. Identify and meet the communication needs of everyone

5. Acknowledge pain and distress and take action

6. Recognize when someone maybe entering the last few days and hours of life

7. Involve people in decision about their care and respect their wishes.

8. Keep the person who is reaching the end of their life and those important to them up to date with any changes in condition

9. Document a summary of conversations and decisions

10. Seek further advice if needed

11. Look after yourself and your colleagues and seek support if you need it

Nursing Roles and Responsibilities

Nurses Bill of rights

created to protect and support nurses as they navigate situations like unsafe staffing, mandatory overtime, violence, and injuries. It protects the nurse's expertise as a professional, giving them the authority to fully express their knowledge and scope of practice without fear of retaliation

1. Right to be trusted by the public

2. Right to practice nursing according to professional standards

3. Right to participate in & to promote growth of the profession

4. Right to intervene when necessary to protect clients

5. Right to be respected for one's own knowledge and abilities

6. Right to be trusted by colleagues

7. Right to give and receive guidance/ correction from colleagues

8. Right to be compensated fairly for services.

NURSES RIGHTS

Ethical Decisions

Involve choosing actions based on moral principles and values. These decisions often require weighing the consequences of actions against ethical standards, such as fairness, justice, and respect for others

Ethical decisions

Refers to the process of evaluating and choosing among alternatives in a manner consistent with ethical principles.

1. Commitment: The desire to do the right thing regardless of the cost

2. Consciousness: The awareness to act consistently and apply moral convictions to daily behavior

3. Competency: The ability to collect and evaluate information, develop alternatives, and foresee potential consequences and risks

The process of making ethical decisions requires

1. The Utilitarian Approach

2. The Right Approach

3. The Fairness or Justice Approach

4. The Common Good Approach

5. The Virtue Approach

FRAMEWORK FOR ETHICAL DECISION MAKING

Utilitarian Approach

Dictates that the action that is the most ethical is the action that produces the greatest balance of good over harm for as many stakeholders as possible

always has a bad side

What is the Dilemma of Utilitarian approach

The Right Approach

suggests that the most ethical decision is the one that best protects and respects the moral rights of all concerned.

The Fairness or Justice Approach

Justice is the idea that each person should be given their due, and what people are due is often interpreted as fair or equal treatment. Equal treatment implies that people should be treated as equals according to some defensible standard such as merit or need

Common Good Approach

Life in community is a good in itself and our actions should contribute to that life.

Virtue approach

An ancient approach to ethics is the belief that acting ethically must be in accordance with certain virtues that ensure the development of humanity in general. Virtues are tendencies and habits that enable man to act with the highest potential of human character.