chapter 16 law and eithics

Laws created for end-of-life decisions:
Legal and ethical dilemmas about a patient’s death created need for laws
Patients have the right to refuse treatment, nutrition, and hydration
Provides provider protection for carrying out wishes

Advance directive:
State’s response to the living will called the Natural Death Act
Includes documents related to end-of-life choices
Includes living will, powers of attorney, healthcare agents, and conservators

Living will (first created in California):
Legal document made stating what treatment a person wants in event of terminal illness
Patients can decide if they want to be kept alive artificially
Specific type of advance directive that outlines wishes for end-of-life

Physicians’ directive (first created in Washington):
Natural Death Act

Physician Orders for Life-Sustaining Treatment (POLST):
Information about resuscitation, advance directives, and other life-sustaining orders

Patient Self-Determination Act (Omnibus Budget Reconciliation Act 1991):
Applies to all facilities that receive payment form Medicare/Medicaid
People get written information about their right to make advance directives
People get written information on choosing what medical/surgical care they want
Does not override state law if provider objects on basis of conscience

Durable Power of Attorney (medical proxy):
Allows a designated person to act on person’s behalf
Person must be competent when signing and is in effect until revoked
People should update every five years and include advance directive

National registry:
People can register their advance directive
Labels to put on insurance card and license
Contacted annually by mail to check for changes

Choices in dying:
Euthanasia Society of America (1938) communication about difficult decisions
Euthanasia Society invented the Living will (1967)
Created to make atmosphere where one could end life
Euthanasia identified as allowing death to come naturally or actively

DNR and DNI:
Do not resuscitate
Do not intubate (tube in airway)

Medication choices:
Based on age, weight, illness (chronic or acute), and person’spain threshold
People with history of substance abuse may refuse opioids (not concern in terminal)

Psychological aspects of dying:
Relationships change, patients may feel like burdens
Some cultures only tell family (not patient) that patient is dying

Hospice:
Cecily Saunders founded in London (1965)
Cardiopulmonary resuscitation, IVs, nasogastric tubes, and antibiotics discouraged

Elisabeth Kubler-Ross's 5 stages of grief:
Denial, Anger, Bargaining, Depression, and Acceptance

TEAR (grief work):
To accept reality of loss
Experience pain of loss
Adjust to environment of what was lost
Reinvest in new reality

Legal definitions of death:
Early definition of cessation of heartbeat and breathing became acceptable
Heart and lung defintion is sometimes found to be insufficient
After heartbeat stops brain death is irreparable within 3 to 4 minutes
Henry Beecher presented concept of brain death
President Reagan formed commission to discuss ethical issues of death (1983)
Commission stated all US jurisdictions accept Uniform Determination of Death Act

Brain death criteria (person appears to be in deep coma):
Unreceptivity and unresponsiveness
No movement or breathing
No reflexes
Flat electroencephalogram

Uniform Determination of Death Act:
Established criteria for death
Irreversible cessation of circulatory/respiratory and brain (including stem)

Legal implications:
Clients with failing kidneys have the right to funding and dialysis
If issue arises referral can be sent to ethics committee
Fear of litigation is why some providers are hesitant to abide by patient wishes

Ethical considerations:
Factors include age, cost, economic status, and health

Cultural views:
Jewish and Mexican people believe death is a part of life
Filipino people believe planning for death is taboo
Chinese believe spirits don’t rest unless grave is cared for and memory is kept
Japanese want to stay by bedside and eldest son makes decisions
Japanese believe it is taboo to discuss serious illness and death
Hmong from Southeast Asia believe organ donation prevents reincarnation
Hmong resist autopsies for same reason
Native Americans resist organ donation due to reverence for the body

Assisted death:
Oregan passed Death with Dignity measure (1994/1997)
Physician can prescribe lethal dose of medication to patient
Law to effect again (1998) 2518 got prescription, 1657 died
Bill to bar government financing for assisted death (1997)
Medicare/Medicaid prohibited from funding
Washington Initiative 1000 (form of Death with Dignity 2009)
Initiative 1000 states patients must have less than 6 months to live

Death with Dignity measure:
Must truly convey informed consent with all feasibleopportunities
Prognosis must be confimed by another physician and verify informed consent
Counseling session must be set up if patient is believed to have depression
Patient must request orally and in writing

Oregon’s Death with Dignity 2019 annual report:
112 physicians wrote 290 prescriptions to qualified patients with 188 deaths

Patient claimed reasons for requested death assistance:
Loss of autonomy
Decreased ability to be active
Loss of dignity

Uniform Anatomical Gift Act (18 plus of sound mind can gift body or organ):
To any hospital or provider for medical/dental education, transplant, or research
To any school
To any organ bank or storage facility
To any individual (written consent with two witnesses)

Gift of Life Organization:
Helps patients that need transplants or persons wanting to donate
HIV patients can sometimes donate

Autopsy authorization:
Coroner and medical examiners can give authorization
Family must give consent

Autopsy authorization (in order of priority):
Surviving spouse
Child of deceased 18 or older
Parent
Adult sibling

Role of health professionals:
Discussions with families
Go-between for family and providers
Discussion on importance of wills and directives
Includes attorneys, chaplains, counselors, and social workers