Learning Plan 05LP05 Assignment: End-of-Life IssuesDirections: In a paper no longer than 1 pageVisit the web site for the American Medical Association and locate the Association’s resources on the ethics of end-of-life care. What are the caregiver’s primary considerations in providing care for a terminal patient? Does the caregiver always provide care that will prolong the patient’s life, or are other considerations appropriate? What issues might arise if the patient’s family disagrees with wishes the patient has previously expressed?

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Chapter 18
End-of-Life Issues
When we finally know we are dying,
And all other sentient beings are dying with us,
We start to have a burning,
almost heart-breaking sense
of the fragility and preciousness of each moment and each
and from this can grow
a deep, clear, limitless compassion for all beings.
—Sogyal Rinpoche
Learning Objectives
➢ Discuss the human struggle to survive and the right to
autonomous decision making.
➢ Describe how patient autonomy has been impacted by
case law and legislative enactments.
➢ Discuss the following concepts: preservation of life with
limits, euthanasia, advance directives, futility of
treatment, withholding and withdrawal of treatment,
and do-not-resuscitate orders.
Learning Objectives (cont’d)
➢ Explain end-of-life issues as they relate to autopsy, organ
donations, research, experimentation, and clinical trials.
➢ Describe how human genetics and stem cell research can
have an impact on end-of-life issues.
Dreams of Immortality
➢ Human struggle to survive
➢ Desire to prevent and cure illness
➢ Advances in medicine and power to prolong life
➢ Ethical and legal issues

Involving entire life span

From right to be born to right to die
Patient Autonomy and Case Law
➢ Right to make one’s own decisions
➢ Patient has the right to accept or refuse care even if it
is beneficial to saving his or her life.
➢ Autonomy may be inapplicable in certain cases.

Affected by one’s disabilities, mental status, maturity, or
incapacity to make decisions
No right is held more sacred, or is more carefully
guarded, by the common law, than the right of
every individual to the possession and control of his
own person, free from all restraint or interference of
others, unless by clear and
authority of law.
—Union Pac. Ry. Co. v. Botsford (1891)
Every human being of adult years and sound mind has a
right to determine what shall be done with his own body
and a surgeon who performs an operation without his
patient’s consent commits an assault, for which he is liable
in damages, except in cases of emergency where the patient
is unconscious and where it is necessary to operate before
consent can be obtained.
—Schloendorff v. Society of New York Hospital (1914)
Why Courts Get Involved
End-of-Life Issues
➢ Family members disagree as to the incompetent’s
➢ Physicians disagree on the prognosis.
➢ A patient’s wishes are unknown because he or she has
always been incompetent.
➢ Evidence exists of wrongful motives or malpractice.
In re Quinlan (1976)
➢ Constitutional right to privacy protects patient’s
right to self-determination.
➢ A state’s interest does not justify interference
with one’s right to refuse treatment.
In re Storar (1981)
➢ Every human being of adult years and sound
mind has the right to determine what shall be
done with his or her own body.
Superintendent of Belchertown State
School v. Saikewicz (1977)
➢ Saikewicz allowed to refuse treatment.
➢ Questions of life and death with regard to an
incompetent should be the responsibility of
the courts.
➢ Court took a “dim view of any attempt to shift
ultimate decision-making responsibility away
from duly established courts of proper
jurisdiction to any committee, panel, or group,
ad hoc or permanent.”
In re Dinnerstein (1978)
➢ “No code” orders are valid to prevent the use of
artificial resuscitative measures on incompetent
terminally ill patients.
In re Spring (1980)
➢ Patient’s mental impairment and his or her
medical prognosis with or without treatment
must be considered prior to seeking judicial
approval to withdraw or withhold treatment
from an incompetent patient.
John F. Kennedy Memorial Hospital v.
Bludworth (1981)
➢ The Florida Supreme Court took the lead and accepted
the living will as persuasive evidence of an
incompetent’s wishes.
➢ The Court allowed an incompetent patient’s wife to act
as his guardian, and in accordance with the terms of a
living will he executed in 1975, she could substitute her
judgment for that of her husband.
Constitutional Right to
Refuse Care
➢ The Supreme Court analyzed the issues
presented in the Cruzan case in terms of a
Fourteenth Amendment liberty interest.
➢ A competent person has a constitutionally protected
right grounded in the due-process clause to refuse
life-saving hydration and nutrition.
Legislative Response
➢ Chief Justice Dore of the Washington Supreme Court
voiced his opinion that a legislative response to
right-to-die issues could be better addressed by
the legislature.
➢ Patient Self-Determination Act of 1990

Enacted to ensure that patients are informed of their rights
to execute advance directives and accept or refuse
medical care
Patient Self-Determination Act of
➢ Enacted to ensure patients are informed of rights to
execute advance directives and accept or refuse
medical care.
➢ Each state is required under PSDA to provide a
description of the law regarding advance directives
to providers.
➢ Whether based on state statutes or judicial decisions
➢ Providers must ensure written policies and procedures
regarding advance directives are established.
Defining Death
Brain Death Criteria
➢ Black’s Law: “irreversible cessation of all brain
functions including the brain stem”
Harvard Ad Hoc Committee on
Brain Death (1968)
➢ Patient shows total unawareness to external stimuli and
unresponsiveness to painful stimuli.
➢ No movements or breathing: All spontaneous muscular
movement, spontaneous respiration, and response to
stimuli are absent.
➢ No reflexes: Fixed, dilated pupils; no eye movement
even when hit or turned, or when ice water is placed in
the ear; no response to noxious stimuli; no tendon
American Medical Association
➢ Committee of the Harvard Medical School to
Examine the Definition of Brain Death
➢ Death occurs when there is “irreversible cessation of
all brain functions, including the brain stem.”
New York Court of Appeals
➢ Evidence of a patient’s intention to reject
prolongation of life by artificial means
➢ Persistence statements regarding individual’s beliefs
➢ Desirability of the commitment to those beliefs
➢ Seriousness with which such statements were made
➢ Inferences that may be drawn from
surrounding circumstances
—In re Westchester County Medical Center ex rel. O’Connor
Futility of Treatment
➢ Physician recognizes effect of treatment will be
of no benefit to the patient.
➢ Morally, a physician has a duty to inform the
patient when there is little likelihood
of success.
➢ Determination as to futility of medical care is a
scientific decision.
Do-Not-Resuscitate Orders
➢ Do-not-resuscitate (DNR) orders written by a
physician indicate that in the event of cardiac or
respiratory arrest no resuscitative measures
should be used to revive the patient.
➢ Competent patients make their own DNR
Withholding and Withdrawal
of Treatment
➢ Withholding of treatment
➢ Decision not to initiate treatment or medical
intervention for the patient
➢ Withdrawal of treatment
➢ Decision to discontinue treatment or medical
interventions for the patient when death is
imminent and cannot be prevented by
available treatment
Withholding and Withdrawal
of Treatment (cont’d)
➢ Considerations
➢ Patient is in a terminal condition and there is a
reasonable expectation of imminent death of
the patient.
➢ Patient is in a non-cognitive state with no reasonable
possibility of regaining cognitive function.
➢ Restoration of cardiac function will last for
brief period.
➢ Mercy killing of hopelessly ill, injured,
or incapacitated
➢ Active euthanasia
➢ Intentional commission of an act, such as giving
patient lethal drug
➢ Passive euthanasia
➢ Occurs when life-saving treatment (such as a
respirator) is withdrawn or withheld
Euthanasia (cont’d)
➢ Voluntary euthanasia
➢ Occurs when suffering incurable patient makes
decision to die
➢ Involuntary euthanasia
➢ Occurs when a person other than incurable makes
decision to terminate life of an incompetent or a
non-consenting competent person’s life
➢ Why
➢ Why Not
➢ How
➢ Who
➢ Where
➢ When
Issues Regarding Euthanasia
➢ If lawful

Long-term ramifications

What about abortions?
➢ Right to die
➢ Civil wrong: Negligence
➢ Criminal offense


Physician-Assisted Suicide
➢ Michigan and assisted suicide
➢ Oregon’s Death with Dignity Act of 1994
➢ U.S. Supreme Court, unanimous and separate

Prohibition of assisted suicide ruled constitutional

Assisted suicide law ruled constitutional
➢ States permitting assisted suicide

Oregon, Washington, and Vermont
Advance Directives
➢ Instructions specifying what actions should be taken in
event the individual becomes incapacitated and can no
longer make healthcare decisions due
to incapacity
➢ Obligation to make preferences known

Patients have an obligation to make care preferences known.

Uncertainty as to patient’s desires should be resolved in favor of
preserving life.
Advance Directives
Living Will
➢ Instrument or legal document that describes
those treatments an individual wishes or does
not wish to receive should he or she become
incapacitated and unable to communicate
treatment decisions
Advance Directives
Healthcare Proxy
➢ Legal document that allows a person to appoint
a healthcare agent to make treatment decisions
in the event he or she becomes incapacitated and
is unable to make decisions for himself or herself
Advance Directives
Durable Power of Attorney
➢ Legal device that permits one individual, known
as the “principal,” to give to another person,
called the “attorney-in-fact,” the authority to act
on his or her behalf
Advance Directives
Surrogate Decision Making
➢ Agent who acts on behalf of a patient who
lacks the capacity to participate in a
particular decision
➢ Substituted judgment

Form of surrogate decision making where surrogate
attempts to establish what decision the patient would have
made if that patient were competent to do so
Advance Directives
➢ Legal mechanism by which the court
declares a person incompetent and appoints
a guardian
➢ Autopsy consent statutes
➢ Authorization by the decedent
➢ Authorization by someone other than
Autopsy (cont’d)
➢ Scope and extent of consent
➢ Fraudulently obtained consent
➢ Unclaimed dead bodies
Organ Donations
➢ Federal regulations require hospitals to have, and
implement, written protocols regarding
organization’s organ procurement.
➢ Regulations impose notification duties
concerning informing families of potential
➢ Discretion and sensitivity should be used in
dealing with families.
Organ Donations (cont’d)
➢ Educating hospital staff on variety of issues involved
with donation matters, in order to facilitate timely
donation and transplantation
➢ Who lives? Who dies? Who decides?
➢ Determination of death
➢ Uniform Anatomical Gift Act
➢ Failure to obtain consent
Research, Experimentation, and
Clinical Trials
➢ Institutional Review Board
➢ Informed consent
➢ Research bill of rights and duty to warn
➢ Failure to obtain informed consent
Research, Experimentation, and
Clinical Trials (cont’d)
➢ Patents delay research
➢ Food and Drug Administration (FDA)
➢ Nursing facilities
➢ Patient understood the risks
Human Genetics
➢ Describes the study of inheritance as it occurs in
human beings
➢ Genetic markers
➢ DNA sequences with a known location on a
chromosome that can be used to identify specific
cells and diseases, as well as individuals
and species
Genetic Information
Nondiscrimination Act (2008)
➢ Prohibits discrimination on the basis of genetic
information with respect to the availability of
health insurance and employment
Stem Cell Research
➢ Embryonic stem cells are used to create organs
and various body tissues.
➢ Opponents argue that use of stem cells is a slippery
slope to reproductive cloning and fundamentally
devalues the worth of a human being.
➢ Medical researchers argue it is necessary to pursue
embryonic stem cell research because the resultant
technologies could have significant medical potential.
Review Questions
1. Describe how patient autonomy has been impacted by
case law and legislative enactments.
2. Discuss the following concepts: preservation of life with
limits, euthanasia, advance directives, futility of
treatment, withholding and withdrawal of treatment,
and do-not-resuscitate orders.
3. Explain end-of-life issues as they relate to autopsy, organ
donations, research experimentation, and clinical trials.
Review Questions (cont’d)
4. Describe how human genetics and stem cell research can
have an impact on end-of-life issues.
5. Discuss the importance of genetic markers.
6. Explain the reason the Genetic Information
Nondiscrimination Act was enacted.

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