GROUP 2

Topic 2: Dignity in Death and Dying

Group Member
 Clemente, Chenie Mave
 Bartolome, Nicole
 Asanji, Aerania
 Bajarin, Jerice

ETHICAL ISSUES CONCERNING LIFE AND DEATH

Life and Death
 When we think about morals, a lot of times we're talking about the best ways to
live long, happy lives. But, that's not always the case. Sometimes we're talking
about death. When is it best to keep someone alive, and when is it best to let
them die? That's a pretty heavy question, and while it may not be the most
cheerful ethical debate, it is important, especially in the world of healthcare.

Inducing Death
 Can death be a more ethical choice than life? That's the question many medical
professionals are asking, specifically in terms of terminally-ill patients. Currently,
modern medicine treats terminal illness, or sicknesses that cannot be cured and
will result in death, in terms of making the patient as comfortable as possible for
the remainder of their lives. But, sometimes this means keeping a patient
constantly sedated with drugs. Other times, there simply is no way to avoid the
pain that comes with a deteriorating condition. So, in these scenarios, where
there is no chance of a recovery, some people are starting to argue that it is
more humane, more ethical, to end a patient's life before suffering gets worse.
 The term for this is euthanasia, which just means intentionally ending a life to
relieve pain or suffering. Euthanasia is distinctly different than murder in that it
is specifically focused on preventing suffering.

Prolonging Life
 So, one side of this debate is focused on when it is best to let someone die. This
ties directly into the other alternative, prolonging life. When is it best to keep a
patient alive, and when can even this cross the line into unethical? Now,
obviously, as long as the patient is conscious and recovering, this is not even
remotely a debate. Even for patients with severe conditions, medical
professionals will attempt to maintain the life of the patient for as long as there
is hope of recovery. The issue arises with patients in comas or similar states
where it's not clear if they will ever be consciously aware again. A patient with a
prolonged state of unconsciousness and lack of response to external stimuli is
referred to as being in a vegetative state.
Ethical Issues in Critical Care Nursing
 Critical care nurses face ethical issues on a daily basis, whether involving
professional ethics or helping a patient or family sort out their own ethical
issues. This lesson touches on a few of the most commonly ethical issues in
critical care nursing: palliative care, withdrawal of care, advance directives, and
medical power of attorney.
 Let's say Patient J has suffered damage to his lungs and can no longer breathe on
his own. He will be attached to a ventilator for the rest of his life, and he needs
to be revived several times a month. However, Patient J is awake and oriented
the majority of the time. During one oriented period, he asks to be made a DNR,
or do-not-resuscitate patient, meaning that if his heart stops again, he doesn't
want to be brought back.
 Patient J's sister doesn't agree with this and tells the hospital her brother isn't
competent. She threatens to sue if the hospital allows her brother to become a
DNR patient. She wants everything done to keep him alive. The cycle of Patient
J's heart stopping and being revived continues for several months. Finally, the
hospital is able to assemble an ethics committee to determine that Patient J is
competent and able to make his own decisions. He chooses to become a DNR
patient and dies peacefully within a few days.

Palliative Care & Withdrawing Care

 In Patient J's situation, once he became a DNR, he didn't remove his ventilator;
he chose palliative care. Palliative care is caring for a patient to relieve pain and
make the dying process as peaceful as possible. Depending on patients' wishes,
they're given food and hydration, but nothing considered a life-saving measure,
such as CPR, dialysis, or surgery, unless a surgery is to relieve pain and not aimed
at curing the patient.
 Had Patient J decided that he wanted to remove the ventilator that was keeping
him alive, he would have been withdrawing care. This is seen a lot in patients
who are brain dead, but their heart is still beating. In this case, all life-saving
components, such as the ventilator and any medications, would be stopped, and
the patient would be allowed to pass away.
 Patient J's scenario is all too common in the intensive care unit. When a patient
is dying, one family member might want everything done to keep the patient
alive, while other family members (or the patient him or herself) might want a
peaceful death. This is when an advance directive or medical power of attorney
is very useful. If the patient has neither, the hospital ethics committee must
determine what the appropriate action is.

Advance Directives
 An advance directive is a statement that is written by the patient and signed by
two witnesses (not family members) that details how the patient would like to
be cared for should he or she become terminally ill or unable to make decisions,
in which case this document appoints someone to make medical decisions for
the patient. Doctors and nurses use this statement to determine what the
 patient's wishes are and make sure they are followed. There are two types of
advance directives: living wills and medical power of attorney.
 When assisting patients in making advance directives, there are a few things to
consider. First, the patient's personal and cultural values and morals must be
taken into account. Additionally, several ethical principles must be considered.
 The first principle is autonomy. Autonomy is the right patients have to choose
what happens to them. Health care workers must respect the patient's choice
and not let their personal beliefs and morals influence the patient. The next
principle is beneficence, which means to do only good and to remove or prevent
harm. Included in that principle is the element of nonmaleficence, which means
to do no harm.

Living Will
 A living will explains how a patient wishes to be cared for when the patient
reaches the end of his or her life. It can be changed anytime and is only made
active once the patient can no longer make decisions. However, in some states,
it can be overturned by the family once the patient is not competent or is
unresponsive. Therefore, it is important that the patient speaks with family
before the time comes and makes sure the family understands and agrees with
the patient's wishes.

Medical Power of Attorney

 A medical power of attorney is a document that gives one person the right to
make all medical decisions for the patient should the patient not be able to
make his or her own decisions. It differs from the living will in that it becomes
active anytime the patient can't make decisions, even if the patient is not
terminal. It also cannot be overturned by family members. However, the
delegated person doesn't have to follow the patient's wishes, so again it is very
important to choose someone who agrees with the patient's wishes.

TERMINATION OF LIFE-SUSTAINING TREATMENT & ETHICS

Life-Sustaining Treatment
 Tragedies that result in sudden death are very hard to deal with. We are forced
to realize that someone that we love is no longer with us. Death takes the
person without consulting us. In other situations, death may creep up over time
and force us to make the decision to let someone go. Deciding to let someone
that you love go is one of the hardest decisions that we are sometimes faced
with in life.
 That decision is usually tied to a terminal illness. Other times it may occur due to
a severe injury that a person is not going to be able to fully recover from, such as
a heart attack or head trauma. There are life-sustaining treatments, which are a
variety of treatments that basically prolong the moment of death. Healthcare
workers and those designated to make decisions for a person in that situation
have to work together to decide if and when these treatments should be
discontinued.

Ethics of Treatment Termination

 One example is Karen Ann Quinlan, a 21 year old that suddenly collapsed and
went into a coma. The doctors put Karen on a respirator and inserted a feeding
tube as life-sustaining measures. The doctors also let Karen's parents know that
she had serious brain damage and was considered to be in a vegetative state.

Personal Impact
 Karen was not proactive by completing an advanced directive, which gives
directions for her care if she cannot communicate. She also did not designate a
healthcare proxy, which is the person who will make healthcare decisions in the
event that she is not conscious or of sound mind to make them herself.
 This would have helped to give an idea of what Karen would want at that point.
There is an argument though that the advance directive does not always reflect
what the person may want if too much time has lapsed since the advance
directive is written, or because people.
 Advance directives can help to determine when life- sustaining treatments
should be terminated tend to feel different about their choices when  they
actually have to face the possibility of dying. 

Socioeconomical Ethics
 In addition to having to make the right ethical decision directly in relation to
Karen, the healthcare team must make the right decision in relation to other
people needing the same treatment that are not terminally ill or possibly at the
end of life. This is a tricky area of ethics because it almost requires healthcare
workers and families to place the value of one person over another.
DYING WITH DIGNITY: DEFINITION & OPTIONS
 When a person is faced with a terminal illness, they sometimes want to control
the timing and way that they die. In this lesson, we'll examine the dying with
dignity movement, including physician-assisted suicide and euthanasia.

Dying with Dignity

 Sarah has had a full and happy life, but she has a terminal illness that is attacking
her central nervous system. Her doctor has told her that she will die from this
disease, but that it will be slow and painful. By the time the disease finally takes
her, Sarah will not be in control of her body anymore. She won't be able to feed
herself or wash herself or even go to the bathroom on her own.
 To Sarah, the thought that she won't be able to take care of herself is worse
than the thought of dying. She doesn't want to linger in pain and lose control of
her body, so she is considering her options. Dying with dignity is a movement
that promotes the ability to meet death on your own terms. Dying with dignity
involves offering options to terminally ill patients, like Sarah, other than just
waiting for the illness to kill them slowly. There are two major ways to die with
dignity: suicide and euthanasia.

SUICIDE
 Suicide is an act or an instance of taking one's own life voluntarily and
intentionally. It is sometimes a way for people to escape pain or suffering.
Concerns regarding the rationality of suicide involve a weighing up of the
positive and negative results of a proposed act of suicide and coming to a
conclusion as to whether the act is of overall benefit or not. One justification
which is held to permit suicide is terminal illness. The thinking behind this is that
the negative value in the person continuing to live in pain with loss of dignity
outweighs other considerations counting against their suicide (Brandt 1980;
Beauchamp 1993). Many people prefer the term assisted death to the term
assisted suicide. Assisted death is an issue where the interests of the individual
cannot be separated from those of society as a whole.

Euthanasia
 The word “euthanasia” itself comes from the Greek words “eu” (good) and
“thanatos” (death). Euthanasia is the practice of ending the life of a patient to
limit the patient's suffering. The patient in question would typically be terminally
ill or experiencing great pain and suffering. A person who undergoes euthanasia
usually has an incurable condition.

2 types of Euthanasia
 Active- Involves directly causing the person's death through an action.
 Passive- involves withholding treatment in away that hastens death.
DEATH AND DYING: EUTHANASIA DEBATE AND STAGES OF
ACCEPTANCE
 Death is the end of life. Death is inevitable. The inevitable end of human life is
death.
 Dying is the process of approaching death, including the choices and actions
involved in that process.

Stages of Grief
 Grief is the response to loss, particularly to the loss of someone or some living
thing that has died, to which a bond or affection was formed.

 Denial- In this stage it makes us survive the loss. We are in the state of
shock and denial. We go numb.
 Anger- is a necessary stage of the healing process. There are many
other emotions under the anger and you will get to them in time, but
anger is the emotion we are most used to managing.
 Bargaining- In this stage We become lost in a maze of “If only…” or
“What if…” statements. We may even bargain with the pain.
 Depression- After bargaining, our attention moves squarely into the
present. This depressive stage feels as though it will last forever. It’s
important to understand that this depression is not a sign of mental
illness. It is the appropriate response to a great loss.
 Acceptance- accepting the reality that our loved one is physically gone
and recognizing that this new reality is the permanent reality.

EUTHANASIA & PHYSICIAN-ASSISTED SUICIDE: A MORAL DEBATE

 Euthanasia or assisted suicide and sometimes both have been legalized in a
small number of countries and states. In all jurisdictions, laws and safeguards
were put in place to prevent abuse and misuse of these practices.
 The legality of euthanasia varies depending on the country. As of June 2021,
euthanasia is legal in Belgium, Canada, Luxembourg, the Netherlands, New
Zealand, Spain and several states of Australia (Queensland, Tasmania, Victoria,
 South Australia and Western Australia). Euthanasia was briefly legal in the
Northern Territory between 1996 and 1997, but was overturned by a federal
law.

Types of Euthanasia
 Ethical arguments vary based on the types of euthanasia that is proposed.

3 Categories of Euthanasia
1. Voluntary Euthanasia
 When the patient’s make’s a request to die.
2. Non-voluntary Euthanasia
 When a person is incapable of making their own decision because of age or
disability, requiring another person to make that choice for them.
3. Involuntary Euthanasia
  Is murder as the person wants to live, but their life s terminated against
their will.

Further euthanasia can be categorized by the degree of involvement in terminating

life.
 Active euthanasia
 Taking deliberate life-ending measures.
 Passive euthanasia
 Allowing a person to die by removing or withholding life-saving
treatment.

Arguments For and Against Euthanasia

 People who advocate for euthanasia typically view making decision about death
as a basic human right that should be made by the patients. End-of-life care is
expensive and draining, and may result suicide. Death with dignity laws allows
the process to be regulated.
 Those who oppose euthanasia frequently have ethical or religious reasons to
oppose interfering with the sanctity of life. There are worries that vulnerable
populations will feel pressured to end their lives to accommodate caregivers.
Further people fear that the quality of care for those who choose to live will be
negatively impacted.

NANCY CRUZAN & LIFE SUPPORT: ETHICAL CASE STUDY

 There are many considerations to account for at the end of someone's life.
Legal, ethical, and moral issues come into play when deciding to remove a
person from life support. We will look at those concerns based on what
happened with Nancy Cruzan.

Life support
 Life support refers to the treatments and machines used to maintain life in a
person whose vital organs are no longer working on their own.
While life support is associated with caring for someone, particularly in late stages of
terminal illness, sudden injuries and illnesses may also be the cause.

Who is Nancy Cruzan?

 Nancy Cruzan was a 25 year old woman in 1983 when she was in a terrible car
accident. She suffered traumatic injuries and had no vital signs such as breathing
or heartbeat when she was found. The emergency responders did CPR to
resuscitate her.
 At the hospital she was put on ordinary care life support, which involves a
feeding tube and hydration. Within about a month, her doctors determined that
she was in a persistent vegetative state (PVS), and would not recover. This
meant she had no brain function and could not respond to her environment.
This is the point when several issues were raised.
Moral and Ethical Concerns
 This is a document that outlines what medical interventions the person would
want and who can speak for them in the event that they cannot speak for
themselves.
 The document includes allowances or cessations for resuscitation and life
support. Without an advance directive, loved ones are forced to request what
they believe to be the wishes of the person who is on life support.
 In Nancy's case, there was no advance directive, but the family and many of her
friends felt they knew her wishes. Her parents requested to have her removed
from life support because they knew she did not want to exist in a vegetative
state and 4 years had already passed since her accident with no change in her
condition.
 Her doctors refused, as they were just giving her the basic of needs: food and
water. They insisted that removing these would kill her and could be seen as
immoral and illegal since she would then die of starvation and dehydration.
 The ethical problem here was whether someone can make the decision to end
another person's life by removing life support. There wasn't anything written to
prove what Nancy would want. Doctors are held to an oath to improve life, and
not to take it away. The burden fell on the family to prove what Nancy would
want since Nancy was clearly unable to do so from a vegetative state.

Legal Concern
 Our Constitution gives us the right to refuse medical treatment, but it does not
outline whether the right still exists in the event that someone is incompetent,
meaning unable to make decisions for themselves. This means that courts are
left to make this decision based on their understanding of the constitution and
rights outlined by the constitutions of their individual states.
 The legal issue becomes even bigger when determining if it is legal or not to
allow someone else to make that decision, and determining where the
differentiation exists between murder and causing death by withholding the
basic needs of life. Who can make that decision and what proof do they need to
show they are acting on the patient's wishes?

Court Decision
 Nancy Cruzan's parents went to the Missouri court system to petition the court
to give the doctors a protective order to allow them to take Nancy off of life
support. The state trial court granted the request based on Nancy's housemate
testifying that Nancy told her that she would not want to live in a vegetative
state. The court decided that the statement was enough since it was made when
Nancy was competent.
 The state supreme court disagreed and reversed the decision, requiring ''clear
and convincing'' evidence of an incompetent person's wishes in such a case.
More than just a housemate's evidence was therefore required in order to grant
the request for Nancy's death. In 1990, the US Supreme court upheld this
decision.