HAS 4400 Chapter 4 End of Life Issues. Definitions of Death Medical –Cessation of respiration, heartbeat and CNS activity. –Brain based: irreversible

HAS 4400

Chapter 4

End of Life Issues

Definitions of Death• Medical

– Cessation of respiration, heartbeat and CNS activity.

– Brain based: irreversible cessation of all brain activity

• Legal– Uniform Determination of Death Act (UDDA)– Brain criteria– Death legally occurs when death is declared.

• Insurance no longer covers medical treatment

Uniformed Anatomical Gift Act

• Individuals of sound mind > 18 years of age are permitted dispose of their own bodies and body parts by will or other written instrument.

• Donation by other than deceased may be made by written, telegraphic, recorded telephonic, or other recorded consent.– Surviving spouse

– Adult child

– Parent

– Adult brother or sister

– Decedent’s guardian

– Any other person or agency authorized to dispose of the body.

Cautious approach to use of non-heart-beating donors The Lancet; London; Aug 12, 2000; Yves

Vanrenterghem; • The first of the reasons for the unpopularity of this donor source is related to the diagnosis of death.

• Normally the diagnosis of death is made on cardiac criteria-eg, cardiopulmonary arrest.

• "When is a NHB donor dead?"

• Although it is now generally accepted that a person is dead when the brain is dead, the duration of absence of circulation before the brain is dead is still not well defined.– Is 2 minutes of cardiopulmonary arrest sufficient, as accepted by the

University of Pittsburg Medical Center

– should it be 5 minutes, as promulgated by the Institute of Medicine of the US National Academy of Sciences

– should there be a wait for 10 minutes between cardiac arrest and any procedure aimed at organ retrieval, as proposed during the 1995 Maastricht workshop

Non-heart-beating organ donation: A defense of the required determination of death

The Journal of Law, Medicine & Ethics; Boston;

Summer 1999; James M DuBois; • DuBois argues that non-heart-beating

organ donation can be ethically justified. Circulatory-respiratory criteria may be used absent brain death to declare death.

Report released by the United Network for Organ Sharing in March

2001

• The waiting list for organ transplants grew 5 times faster than the number of organ transplants during the past decade

• The list tops 75,000 Americans

• An average of 15 people in the US die every day waiting for an organ transplant.

China's bitter harvest The theft and sale of human body parts; Foshan, China

U.S. News & World Report; Washington; Feb 5, 2001; Bay Fang

In China, doctors are taking organs and tissue from dead bodies without permission, and Chinese authorities are selling organs taken from executed prisoners. The government so far has failed to curb such abuses.

Britain: The return of the bodysnatchers The Economist; London; Feb 3,

2001; Anonymous; A report of the ghoulish malpractice and gross

mismanagement at Alder Hey children's hospital in Liverpool revealed that, between 1988 and 1995, all the organs of all the children who had post-mortems at the hospital were systematically stripped, on the instructions of Dick van Velzen, a pathologist. Van Velzen failed to obtain parents' consent for these procedures, and lied to them and his own colleagues, who in turn failed to stop him. In response to these revelations, the government has promised to update the murky law governing the consent doctors need from relatives before a post-mortem. And a commission has been established to oversee the return of organs stored across the country to relatives who care to claim them

Unclaimed bodies

• Person entitled to possession of a dead body must arrange for release of the body for transfer to an undertaker.

• If unclaimed, state statute applies.– Usually buried at public expense

– May be transferred to an institution for educational scientific purposes.

– Bodies of persons dying from contagious disease are not distributed.

Ethical Responses to End of Life Issues

The Hemlock Society

"The right to die should include...the ability to enlist assistance from...the medical profession in making death as quick and painless as possible...If there is ever a time when we ought to be able to get the government off our backs it is when we face death"

Justice Lynn Compton, Bouvla Decision, 1986

Hemlock believes that people should be able to have choice and dignity at the end of life.

End of Life Issues

• Advance Directive

• Euthanasia

• Treatment of the Terminally Ill

Advance Directives(Living Wills)

• A vehicle which allows for continuation of negotiations between physician and patient after the patient has been temporarily or permanently rendered incompetent.

• Two forms:– Instruction directive– Proxy directive (Durable Power of Attorney)

Four Situations1. A person sustains a head injury and is

conscious but incoherent or in a coma from which they may or may not recover.

2. A person is in an irreversible coma or persistent vegetative state with no possibility of recovery.

3. A person suffers irreversible brain damage but otherwise is healthy.

4. A person has a degenerative brain disease and develops a terminal disease such as cancer or blockage of a coronary artery.

Ten Treatmentsthat could require advanced directives

1. Cardiopulmonary Resuscitation (CPR)

2. Mechanical Breathing--Being on a Respirator or Ventilator

3. Tube Feeding

4. Kidney Dialysis or Hemodialysis.

5. Diagnostic Tests

6. Surgery

7. Chemotherapy

8. Transfusions

9. Antibiotics

10. Pain Medication within a Regimen of Palliative Care

Appointing a Health Care Proxy

• Durable power of attorney for Health Care.– Goes into effect after the onset of

incompetence and pertains specifically to health care decisions.

• Proxy can approve or reject any and all treatments and procedures.

• Picking a proxy is critical– They should be well known and trusted.

Arguments for and against Euthanasia

God had dominion over life’s end. Humans should not intrude into this area.

God’s dominion is not relevant to nonbeliever’s. In addition, some people who believe in God believe in a God who would not want dying prolonged.

ForAgainst

There is a tradition in Western civilization against taking innocent life by overt means. It would be a mistake to abandon that tradition.

Western civilization is just one civilization among many. The test of any culture is its ability to adjust and adapt to the issues of its time.

Arguments for and against EuthanasiaForAgainst

The humane response to the suffering person is to tend to her needs, not to kill her. Suffering can be lessened with out killing the patient. Killing someone represents an inhumane experience for both the person who carries out the deed and the person who is killed.

Ending suffering is a lesser evil than prolonging suffering. We need to respond to the sick and dying who request deliverance with compassion and assistance.


All people have a duty not to commit suicide. There is value and dignity to human life, even in dying.

The life of a suffering person may become useless, at which time the person may choose to have his life ended.


It is hard to impossible to ascertain whether or not the decision for euthanasia is sane, sound, and rational. Most very sick people are also depressed. Additionally, oftentimes such people can be subject to coercion for those who could benefit from their deaths.

Let a person implement his own choices. Depressed people can make rational choices and so can people whose relatives would be relieved by their demise.


Involving physicians and nurses in direct, active euthanasia erodes the ethical foundations of medicine and nursing.

Physicians and nurses are in the best position to aid the terminally ill in dying. Those who hold no ethical scruples about practicing euthanasia should not be prohibited from so doing by professional codes or civil laws.


By implementing direct active euthanasia, we would arrange gruesome, dehumanizing scenarios.

To set the time, place, and scenario for death would not be inhumane. It would be stressful, but there is no denying that death is a stressful event. To be sure, it is easier to deal with the end of a loved one’s suffering than it is to watch the loved one’s suffering continue.


Legalized euthanasia would add to the fears of the sick and dying who would be afraid of being victims of involuntary positive euthanasia.

Sick people would be better off if they thought they could manage their dying.


The Supreme CourtJune 27, 1997

• States may continue to ban Physician assisted suicide.

• 9-0 vote• The Constitution does not grant a right to the

physician-assisted suicide. (does not violate the 14th Amendment.)

• No reason to collapse the distinction between “assisting suicide and withdrawing life-sustaining treatment….”

Reuters News

• The Netherlands Tuesday became the first country in the world to legalize euthanasia after its Senate defied thousands of protesters to vote in favor of mercy killing.

• Wednesday April 11 12:02 PM ET Vatican Newspaper Blasts Dutch Euthanasia Law

• The Vatican blasted the Netherlands' decision to become the first country to legalize euthanasia, calling it abhorrent and criminal, and the doctors who perform it ``butchers.''

Documents

HAS 4400 Chapter 4 End of Life Issues. Definitions of Death Medical –Cessation of respiration, heartbeat and CNS activity. –Brain based: irreversible