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Chapter 12: Death and Dying Notes

Learning Outcomes

  • 12.1: Summarize attitudes toward death and criteria for determining death.
  • 12.2: Describe legal documents used in end-of-life decisions.
  • 12.3: Identify health care services for patients with a terminal illness.
  • 12.4: Describe the right-to-die movement.
  • 12.5: Identify the major features of organ donation in the U.S.
  • 12.6: List the various stages of grief.

Determination of Death

  • Uniform Determination of Death Act: Proposed in 1981 by the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical Research. States have their own criteria.
    • Definition of Brain Death:
    • Circulatory and respiratory functions have irreversibly ceased.
    • The entire brain, including the brain stem, has irreversibly ceased to function.

Brain Injury States

  • Coma: A state of deep stupor where the patient cannot be roused by external stimuli.
  • Persistent Vegetative State: Severe mental impairment with irreversible cessation of higher brain functions, often from damage to the cerebral cortex.

Signs of Death

  • Inability to breathe without assistance.
  • Absence of coughing or gagging reflex.
  • No pupil response to light.
  • No blinking reflex when the cornea is touched.
  • No grimace reflex when head rotated or ears flushed with ice water.
  • No response to pain.

Autopsy

  • A postmortem examination for determining the cause of death or obtaining physiological evidence if necessary.
  • Can confirm or correct clinical diagnoses, especially in suspicious deaths or homicide cases.

Patient Self-Determination Act (PSDA)

  • Enacted in 1990, requires providers to ask patients about advance directives.
    • Advance Directives include:
    • Living Will: Specifies end-of-life wishes.
    • Durable Power of Attorney: Grants a designee authority to make various legal decisions, including health care decisions.
    • Health Care Proxy: Identifies a specific person to make health care decisions when the patient cannot.
    • Do-Not-Resuscitate (DNR): An order to not use CPR to sustain life during a medical crisis.
  • Providers must document advance directives in patient records without discrimination and comply with state laws regarding them.

Types of Advance Directives

  1. Living Will: Outlines a person's end-of-life wishes.
  2. Durable Power of Attorney: Grants authority to make legal decisions on the grantor's behalf, especially regarding health care.
  3. Health Care Power of Attorney: Specifically identifies a person for making health care decisions.
  4. DNR Order: Prevents the use of CPR in dire medical situations.

Palliative and Curative Care

  • Palliative Care: Focuses on symptom management to make dying comfortable, also termed comfort care.
  • Curative Care: Aimed at curing diseases.

Hospice Services

  • Targeted at terminal illness patients and their families, available in different settings (home, nursing home, hospital).
  • Includes a multi-disciplinary team:
    • Physicians, nurses, home health aides, social workers, physical therapists, and other specialists.

End-of-Life Discussion Training

  • Medical and nursing schools now require training in end-of-life care and palliative care competencies.
  • Medicare reimburses physicians for advance directive discussions with patients.

Palliative Care Certifications

  • Medical board specialties in palliative care.
  • Certification programs offered for advanced registered nurse practitioners (ARNP) and social workers in palliative care.

Right-to-Die Movement

  • Gained attention from the Karen Ann Quinlan case (1976).
  • Uniform Rights of the Terminally Ill Act: Provides guidelines for state laws on advance directives.
  • Currently, eight states and D.C. have Death with Dignity laws: Oregon, Washington, Montana, Vermont, California, Colorado, New Jersey, Hawaii, and Washington, D.C.

Euthanasia and Physician-Assisted Suicide

  • Types include:
    • Active euthanasia
    • Passive euthanasia
    • Voluntary euthanasia
    • Involuntary euthanasia

National Organ Transplant Act

  • Passed in 1984 to provide grants to organ procurement organizations, establishing the Organ Procurement and Transplantation Network (OPTN).

OPTN Goals

  • Increase transplants and ensure equitable access.
  • Improve outcomes for patients on the waiting list, living donors, and transplant recipients.
  • Promote the safety of living donors and recipients, and efficient management of the OPTN.

Uniform Anatomical Gift Act

  • Established to allow individuals to donate bodies or parts for transplantation, tissue banks, or medical research/education.

Organs/Tissues for Transplantation

  • Organs: Heart, kidneys, pancreas, lungs, stomach, intestines.
  • Tissues: Bone, corneas, skin, heart valves, veins, cartilage, other connective tissues.

Stages of Grief (Kübler-Ross Model)

  • Not in specific order:
    1. Denial
    2. Anger
    3. Bargaining
    4. Depression
    5. Acceptance