Group 5: Adlawan, Arceo, Desuyo, Eullaran, Lendio, Rubillar, Sison, Tegio
COURSE OUTLINE: e) Self-administered
1. Euthanasia and Prolongation of Life
2. Inviolability of Human Life
3. Euthanasia and Suicide
4. Dysthanasia
5. Orthothanasia
6. Administration of Drugs to the Dying
7. Advance Directives
8. DNR or End of Life Care Plan
Euthanasia and Prolongation of Life
- 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.
- The word “euthanasia” itself comes from the Greek
words “eu” (good) and “thanatos” (death).  The idea
is that instead of condemning someone to a slow,
painful, or undignified death, euthanasia would
allow the patient to experience a relatively “good
death.”
TYPES OF EUTHANASIA:
a) Active euthanasia: killing a patient by active means,
for example, injecting a patient with a lethal dose of
a drug.  Sometimes called “aggressive” euthanasia.
b) Passive euthanasia: intentionally letting a patient
die by withholding artificial life support such as a
ventilator or feeding tube.  Some ethicists
distinguish between withholding life support and
withdrawing life support (the patient is on life
support but then removed from it).
c) Voluntary euthanasia: with the consent of the
patient.
d) Involuntary euthanasia: without the consent of the
patient, for example, if the patient is unconscious
and his or her wishes are unknown.  Some ethicists
distinguish between “involuntary” (against the
patient’s wishes) and “nonvoluntary” (without the
patient’s consent but wishes are unknown) forms.
euthanasia: the patient
administers the means of death.
f) Other-administered euthanasia: a person other
than the patient administers the means of death.
g) Assisted: the patient administers the means of
death but with the assistance of another person,
such as a physician.
h) Mercy-killing: The term “mercy-killing” usually
refers to active, involuntary or nonvoluntary,
other-administered euthanasia.  In other words,
someone kills a patient without their explicit
consent to end the patient’s suffering.
i) Physician-assisted suicide: The phrase
“physician-assisted suicide” refers to active,
voluntary, assisted euthanasia where a physician
assists the patient.  A physician provides the patient
with a means, such as sufficient medication, for the
patient to kill him or herself.
What is Life-Prolonging Treatment?
There are many kinds of treatment that can help you
live longer. These may be needed for only a short time
until your illness improves. Or you may use them over
the long term to help keep you alive.
Some treatments include the use of:
● Medicines to slow the progress of certain diseases,
such as heart disease, diabetes, cancer, AIDS, or
Alzheimer's disease.
● Antibiotics to treat serious infections, such as
pneumonia.
● Dialysis to clean your blood if your kidneys stop
working.
● A breathing machine to help you breathe if you
can't breathe on your own. This machine pumps air
into your lungs through a tube put into your throat.
● A feeding tube or an intravenous (IV) line to give
you food and fluids if you can't eat or drink.
● Cardiopulmonary resuscitation (CPR) to try to
restart your heart.
KEY POINTS IN THIS DECISION
- If there is a good chance that your illness can be
cured or managed, your doctor may advise you to
first try available treatments. If these don't work,
then you might think about stopping treatment.
- If you stop treatment, you will still receive care that
focuses on pain relief and comfort.
- A decision to stop treatment that keeps you alive
does not have to be permanent. You can always
change your mind if your health starts to improve.
- Even though treatment focuses on helping you live
longer, it may cause side effects that can greatly
affect your quality of life. And it could affect how
you spend time with your family and friends.
- If you still have personal goals that you want to
pursue, you may want treatment that keeps you
alive long enough to reach them.
WHY MIGHT YOU CHOOSE LIFE-PROLONGING
TREATMENT
- There is a good chance that your illness can be
cured or managed.
- You think you can manage the possible side effects
of treatment.
- You don't think treatment will get in the way of your
quality of life.
- You have personal goals that you still want to pursue
and achieve.
Inviolability of Human Life
- Refers to the sanctity, dignity or respect for human
life
- In John Keown’s The Law and Ethics of Medicine,
there are three different approaches to the value of
human beings: Quality of Life, Inviolability of Life,
and Vitalism.
- Inviolability of human life (IOL) is a fundamental
principle of common law and of ethics. Human life
itself is a basic, intrinsic good. It is the theological or
philosophical understanding that all human life has
an inherent dignity.
- For Christians, human life is sacred and is a gift from
God which is to be respected and protected.
Human life is precious because:
● It is a gift from God which is forever
● It is an expression of love
● It is the fruit of love
- No amount of money can surmount its cost
THE SANCTITY OF LIFE DATE: DAVID P. GUSHEE
“The concept of the sanctity of life is the belief that all
human beings, at any and every stage of life, in any and
every state of consciousness or self-awareness, of any
and every race, color, ethnicity, level of intelligence,
religion, language, gender, character, behavior, physical
ability/disability, potential, class, social status, etc., of
any and every particular quality of relationship to the
viewing subject, are to be perceived as persons of equal
and immeasurable worth and of inviolable dignity
therefore must be treated in a manner commensurate
with this moral status.”
This concept of the inviolability of life by David Gushee
can be explained in four points:
1. The sanctity of life is a concept that one believes.
2. It is a moral conviction about how human beings are
to be perceived and treated.
3. It is universal. The sanctity of life is among the
broadest and most inclusive understandings
possible of our moral obligations to other human
beings.
4. All human beings are included, at all stages of
existence, with every quality of experience,
reflecting every type of human diversity, and
encompassing every possible quality of relationship
to the person who does the perceiving.
● The Inviolability of Life view is that intentional
killing is not ethical and should not be legally
permissible, yet that it is often acceptable to
withdraw life support. Even if a particular medical
treatment is worthless, the human patient is never
worthless.
● The Inviolability of Life principle allows that if some
treatment is more burdensome than beneficial, it
may be withheld or withdrawn, even if the patient’s
life is shortened as a side effect. 
Group 5: Adlawan, Arceo, Desuyo, Eullaran, Lendio, Rubillar, Sison, Tegio
EUTHANASIA AND SUICIDE
- Euthanasia and physician-assisted suicide refer to a
deliberate action taken with the intention of ending
a life to relieve persistent pain.
- In most countries, euthanasia is against the law and
may carry a jail sentence. In the United States, the
law varies between states.
- Euthanasia has long been a controversial and
emotive topic.
● Euthanasia: A doctor is allowed by law to end a
person’s life by a painless means, as long as the
person and their family agree.
● Assisted suicide: A doctor assists an individual in
taking their own life if the person requests it.
VOLUNTARY AND INVOLUNTARY EUTHANASIA
● Voluntary: When euthanasia is conducted with
consent. Voluntary euthanasia is currently legal in
Australia, Belgium, Canada, Colombia, Luxembourg,
The Netherlands, Spain, Switzerland, and New
Zealand. It is also legal in the U.S. states of Oregon,
Washington D.C., Hawaii, Washington, Maine,
Colorado, New Jersey, California, and Vermont.
● Non-voluntary: When euthanasia is conducted on a
person who is unable to consent due to their
current health condition. In this situation, the
decision is made by another appropriate person, on
behalf of the individual, based on their quality of
life.
● Involuntary: When euthanasia is performed on a
person who would be able to provide informed
consent, but does not, either because they do not
want to die, or because they were not asked. This is
called murder, as it’s often against the person’s will.
ASSISTED SUICIDE
Assisted suicide has several different interpretations and
definitions.
Trusted Source One is:
“Intentionally helping a person take their own life by
providing drugs for self-administration, at that person’s
voluntary and competent request.”
Some definitions include the words, “in order to relieve
intractable (persistent, unstoppable) suffering.
HIPPOCRATIC OATH
The original oath included, among other things, the
following words:
“I will neither give a deadly drug to anybody who asked
for it, nor will I make a suggestion to this effect.”
There are variations of the modern oath.
One states:
“If it is given me to save a life, all thanks. But it may also
be within my power to take a life; this awesome
responsibility must be faced with great humbleness and
awareness of my own frailty.”
- As the world has changed since the time of
Hippocrates, some feel that the original oath is
outdated. In some countries, an updated version is
used, while in others, for example, in Pakistan,
doctors still adhere to the original.
- As more treatments become available, for example,
the possibility of extending life, whatever its quality,
is an increasingly complex issue.
EUTHANASIA IN UNITED STATES
- In the U.S. and other countries, euthanasia has been
a topic of debate since the early 1800s.
- In 1828, the first anti-euthanasia law in the U.S. was
passed in New York state. In time, other states
followed suit.
- In the 20th century, Ezekiel Emmanual, a bioethicist
of the American National Institutes of Health (NIH)
said that the modern era of euthanasia was ushered
in by the availability of anesthesia.
- In 1938, a euthanasia society was established in the
U.S., to lobby for assisted suicide.
- Physician-assisted suicide became legal in
Switzerland in 1937, as long as the doctor ending
the patient’s life had nothing to gain.
- During the 1960s, advocacy for a right-to-die
approach to euthanasia grew.
- The Netherlands decriminalized doctor-assisted
suicide and loosened some restrictions in 2002. In
2002 doctor-assisted suicide was approved in
Belgium.
- In the U.S., formal ethics committees now exist in
hospitals and nursing homes, and advance health
directives, or living wills, are common around the
world. These became legal in California in 1977,
with other states soon following suit. In the living
will, the person states their wishes for medical care,
should they become unable to make their own
decision.
- In 1990 the Supreme Court approved the use of
non-active euthanasia.
- In 1994, voters in Oregon approved the Death with
Dignity Act, allowing physicians to assist people with
terminal conditions who were not expected to
survive more than 6 months.
- The US Supreme Court adopted such laws in 1997,
and Texas made non-active euthanasia legal in 1999.
- The Terri Schiavo case galvanized public opinion in
Florida and the U.S. Schiavo had a cardiac arrest in
1990 and spent 15 years in a vegetative state before
her husband’s request to allow her to die was
granted.
- The case involved various decisions, appeals,
motions, petitions, and court hearings over a
number of years before the decision was made to
disconnect Schiavo’s life support in 2005.
- The Florida Legislature, U.S. Congress, and President
Bush all played a role.
- In 2008, 57.91% of voters in Washington state chose
in favor of the Death with Dignity Act, and the act
became law in 2009.
Arguments for
● Freedom of choice: Advocates argue that the
person should be able to make their own choice.
● Quality of life: Only the individual really knows how
they feel, and how the physical and emotional pain
of illness and prolonged death impacts their quality
of life.
● Dignity: Every individual should be able to die with
dignity.
● Witnesses: Many who witness the slow death of
others believe that assisted death should be
allowed.
● Resources: It makes more sense to channel the
resources of highly skilled staff, equipment, hospital
beds, and medications toward life-saving treatments
for those who wish to live, rather than those who
do not.
● Humane: It is more humane to allow a person with
intractable suffering to be allowed to choose to end
that suffering.
● Loved ones: It can help to shorten the grief and
suffering of loved ones.
● We already do it: If a beloved pet has intractable
suffering, it is seen as an act of kindness to put it to
sleep. Why should this kindness be denied to
humans?
Arguments against
● The doctor’s role: Healthcare professionals may be
unwilling to compromise their professional roles,
especially in the light of the Hippocratic Oath.
● Moral and religious arguments: Several faiths see
euthanasia as a form of murder and morally
unacceptable. Suicide, too, is “illegal” in some
religions. Morally, there is an argument that
euthanasia will weaken society’s respect for the
sanctity of life.
● Patient competence: Euthanasia is only voluntary if
the patient is mentally competent, with a lucid
understanding of available options and
consequences, and the ability to express that
understanding and their wish to terminate their
own life. Determining or defining competence is not
straightforward.
● Guilt: Patients may feel they are a burden on
resources and are psychologically pressured into
consenting. They may feel that the financial,
emotional, and mental burden on their family is too
great. Even if the costs of treatment are provided by
the state, there is a risk that hospital personnel may
have an economic incentive to encourage
euthanasia consent.
● Mental illness: A person with depression is more
likely
Group 5: Adlawan, Arceo, Desuyo, Eullaran, Lendio, Rubillar, Sison, Tegio
Statistics
- Opinions appear to be growing in favor of
euthanasia and assisted suicide.
- In 2013, researchers published findings of a survey
in which they asked people from 74 countries their
opinions on physician-assisted suicide.
- Overall, 65% of respondents voted against
physician-assisted suicide. In 11 of the 74 countries,
the vote was mostly for.
- In the U.S., where 1,712 respondents represented
49 states, 67% voted against it. In 18 states, the
majority were for physician-assisted suicide. These
18 did not include Washington or Oregon.
- In 2017, a Gallup poll indicated that 73% of
respondents were in favor of euthanasia in the U.S.,
and 67% were in favor of doctor-assisted suicide.
- Among weekly churchgoers, Gallup found that 55%
were in favor of allowing a doctor to end the life of a
patient who is terminally ill, compared with 87% of
those who do not regularly attend church.
- It is also a political issue. Gallup’s 2017 poll found
that almost 9 out of 10 liberals are in favor,
compared with 79% of moderates and 60% of
conservatives.
How many people die each year?
- In countries where euthanasia or assisted suicide
are legal, they are responsible for between 0.3 and
4.6% of deaths, over 70% of which are linked to
cancer. In Oregon and Washington states, fewer
than 1% of physicians write prescriptions that will
assist suicide each year.
DYSTHANASIA
Concept of Dysthanasia
- The increase in life expectancy owes much of its
accomplishments, so far as Medicine is concerned,
to the technological achievements which can
directly influence the natural history of end of life.
- In terms of concept, the end of life or death has two
moments: The process of death and the moments
of death. While the latter is the moment of
irreversibility, the former―the process of
death―can be swayed in either way; in
fastening―euthanasia or in retarding―dysthanasia.
- Dysthanasia from Greek, dysthanatos, turning death
difficult. In a broad sense it can be understood as
medical stubbornness or a futile treatment. In good
medical practice the treatment should be
proportional to the expected prognosis. If the
treatment provided clearly overcomes the expected
prognosis retarding the process of dying and
prolonging the agony and suffering of the patient,
then it seems clear that it is a case of dysthanasia.
- The concept of dysthanasia, proposed initially by
Morache in the book “Naissance et mort”, is
etymologically derived from the Greek and it results
from the prefix dis, distance, wrongly done, and the
substantive thanatus, death. Dysthanasia therefore
refers to digression of death, the botched death, a
difficult death or, more precisely, under Brito and
Rijo’s perspective 3 , extending a patient’s life
beyond his natural period.
- While for Leo Pessini, the author of the book
“Dysthanasia: Until when to prolong life?” defines
dysthanasia as a “slow, painful death in immense
suffering,” in other words “merciless prolongation of
life”, but the first bioethicist who used that term and
suggested that it be used within bioethics was
Leonard M. Martin . The term in question is a
neology of Greek origin, in which the prefix dys
signifies a “wrongful act.” Therefore, dysthanasia
etymologically signifies exaggerated prolongation of
agony, suffering, and death of the patient. The
concept can be employed as a synonym for futile
and useless treatment, that consequently medically
assists slow and prolonged death followed by
suffering. Such behavior does not prolong life –
considering its quality – but the process of dying.
For such situations the French syntagm of
“therapeutic perseverance” (L’acharnement
thérapeutique) is most often used in Europe. In the
USA “medical futility,” “futile treatment,” or simply
“futility,” are most often used. When discussing
dysthanasia it is commendable to employ the
syntagm “futile treatment”.
- Although less disseminated than euthanasia,
dysthanasia is, albeit unconsciously, most practiced.
Although opposite, both are ethically condemned
 for Archer 1 because, roughly speaking, one
anticipates the death of a person still alive and the
other extends the life of a person already dead.
Despite the difference, as affirmed by Pessini 2, they
cause death unexpectedly.
- Such definition apparently simple raises complex
questions on what life is and on quality of life.
Dysthanasia: The Underlying Rationale
DEFENSIVE MEDICINE
- The reason for being of dysthanasia has been
bestowed on defensive medicine, a physician
response, fully or partly prompted, to protect him
from an incrimination of bad medical practice.
- The defensive medicine can be positive or negative.
In the first case the physician carries out
unnecessary procedures to guard against that
accusation, while in the second situation he avoids
the procedures to safeguard from the same
accusation.
- So far as dysthanasia is concerned, it is the positive
defensive medicine that is at stake.
- In short, we can say that in defensive medicine, the
physician procedures result not from his
deep-rooted values and beliefs but from the
self-protection against charges of malpractice, in the
event of an unfavorable outcome of treatment, by
the society.
 DIALECTIC OF TECHNOLOGY
- It is well known that the dialectic is inherent to the
technology. A justification for the therapeutic
obstinacy could find a support in the
overspecialization, characteristic to the high
technology, which leads to the fractioning of the
knowledge; this entails to the splitting of skills that
ends up in the unaccountability in the
decision-making process.
- In the advanced stages of some diseases when the
multi organ failure foresees an unfavorable
prognosis, the unaccountability of the various
experts in regarding the inevitable outcome can
explain the maintenance of the treatments.
CONFLICT OF VALUES
- The collision of values can also explain the
therapeutic obstinacy. This can be found out in the
universal Declaration of Human Rights, signed on
10th December of 1948 by the United Nations
General Assembly.
- In Article 3, it states that “Everyone has the right to
life, liberty and security of person”, while in Article 5
it says that “No one shall be subjected to torture or
to cruel, inhuman or degrading treatment or
punishment” (Universal Declaration Human Rights,
1948) .
- These two articles are facing each other especially
when apparently it is a situation of therapeutic
obstinacy. It is a situation of conflict of values and
rights and thus, an ethical conflict since what is at
stake is opposing imperatives.
EXISTENTIALISM AND METAPHYSICS
- The impact of technology in the conceit of death,
changed thoroughly, in the developed countries, the
way of staring the end of life.
- Through the intervention of technology, the
moment of death has been heralded by the process
of death. These two moments―the moment of
death and the process of death―beget different
feelings.
- As for the moment of death, according to Ernest
Becker “The fall into self-cons- ciousness, the
emergence from comfortable ignorance in nature,
had one great penalty for man: it gave him dread, or
anxiety.” (Becker, 1973) .
- However, Ernst Bloch denies this anguish of death
and refuses the failure, having in mind that there is
always an exit―the hope (Block, 1982) . This escape
from anguish conceived by the moment of death
and hope bring in transcendence in the process of
death can explain the use of technology in
dystanasia.
- It may be easily concluded that the balance
between not killing and not postponing death is
fragile and that dysthanasia and passive euthanasia
have been often confused. Moreover, the ethical
principles that underpin dysthanasia practices or its
negation are very interwoven: dysthanasia
underlines the ethical principle of beneficence that
can be understood as the self-respect transposed to
third parties and that defines good and determines
that it be accomplished, what underlies a medical
Group 5: Adlawan, Arceo, Desuyo, Eullaran, Lendio, Rubillar, Sison, Tegio
commitment to engage all feasible efforts and
technical means to keep the patient alive. The
denial of dysthanasia has the principle of
non-malfeasance underlined, related to the primum
non nocere maxim, as part of the principle that any
therapeutic intensification only prolongs or
increases the ill-person’s suffering.
- the Deontological Code of Nursing 22 seems not to
raise this kind of ambivalence. Article 82 clarifies
that nurse, in respect of the person’s right to life
throughout the life cycle, assumes the duty of
respecting the individual’s biopsychosocial, cultural
and spiritual integrity, and Article 87 states that the
nurse should monitor the patient in the different
stages of the terminal stage.
ORTHANASIA
The word Orthothanasia dates back to the
1950’s, its etymology being “correct dying”.
Orthotanasia refers to the art of promoting a
humane and correct death, not subjecting patients
to misthanasia or dysthanasia and not abbreviating
death either, that is, subjecting them to euthanasia.
Its great challenge is to enable terminal patients to
keep their dignity, where there is a commitment to
the well-being of patients in the final phase of a
disease.
As treatments can no longer restore health,
attempts at healing become futile; one has to keep
in mind that care is part of the treatment, not to
incur dysthanasia. When the treatment no longer
meets its objectives, when there are no real
possibilities of success or improved quality of life,
treatment becomes futile. Hence, one needs to stop
useless measures and transfer efforts to alleviate
pain, suffering, and the discomfort of dying,
providing natural death, Death has no cure. It is
noble to assume it is part of life.
Orthothanasia is a more positive dimension
of the right to die and consists of dying humanely,
peacefully, an ideal death. It is the process of the
humanization of death and alleviation of pain, but it
does not abusively prolong death with the
implementation of futile treatment, which would
cause more suffering to terminal patients. Thus
Orthonasia is much more preferred by health
professionals compared to dysthanasia.
A movement called dying with dignity has
recently arose in the recent years, Dignity in Dying
campaigns for the greater choice, control and
access to a full range of medical and palliative
services at the end-of-life, including providing
terminally ill adults with the option of a painless,
assisted death, within strict legal safeguards.
ADMINISTRATION OF DRUGS TO THE DYING
In medicine, specifically in end-of-life care,
palliative sedation is the practice of relieving
distress in a terminally ill person in the last hours or
days of a patient's life, usually by means of a
continuous intravenous or subcutaneous infusion of
a sedative drug, or by means of a specialized
catheter designed to provide comfortable and
discreet administration of ongoing medications via
the rectal route. Usually, a doctor or nurse is in
charge of giving out the sedative. In some
instances, doctors give patients drugs that render
them unconscious and deeply relaxed until death
occurs. Opioids, benzodiazepines, and
nonbenzodiazepine hypnotics are the medications
most frequently used to induce palliative sedation.
Palliative sedation is an option of last resort for
patients whose symptoms cannot be controlled by
any other means. Palliative sedation is also an
advanced medical procedure that requires the
patient to receive intravenous (IV) medications
and/or other forms of treatment to promote
unconsciousness and a deep level of relaxation
until death occurs. It is not a form of euthanasia, as
the goal of palliative sedation is to control
symptoms rather than shorten the patient's life.
Some say that it is considered when other
treatment options have failed.
 TYPES OF ADVANCE DIRECTIVES
ADVANCE DIRECTIVES
What kind of medical care would you want if you
were too ill or hurt to express your wishes?
Advance directives are legal documents that allow
you to spell out your decisions about end-of-life
care ahead of time. They give you a way to tell your
wishes to family, friends, and health care
professionals and to avoid confusion later on.
WHAT ARE ADVANCE DIRECTIVES?
● Advance directives are legal documents that
state the patient's wishes when the patient
becomes unable to speak for themselves.
● It is created ahead of any medical
incapacitation in order to ensure that the
patient has the ability to make their own
decisions when they are unable to do so.
(Morrison, 2010).
UNDERSTANDING ADVANCE DIRECTIVES
Should you become unable to communicate from
reasons of mental or physical incapacity, one may
be able to issue an advanced directive so as to
detail your choices for health care and treatment.
To understand better, let us have a look at a sample
advanced directive…
In this letter, said patient is in the state of Dementia,
a loss of cognitive functioning — thinking,
remembering, and reasoning. Within it are 4
conditions or wishes the patient desires, completed
by the family members with the aid of an advanced
directive.
1. Living Will
● A living will is a legal document that
discloses a person's individual needs and
requests when unable to make a competent
decision on their own.
● Living will should be validated by two
witnesses that are not related to the patient.
(Morrison, 2010)
● Decisions that a living will can address are:
➢ Life-support treatments such as mechanical
ventilation, cardiopulmonary resuscitation
(CPR) and life sustaining medications.
➢ Nutrition and hydration - feeding tubes &
artificial nutrition
➢ Guardianship or decision making
appointment.
➢ Dialysis and organ donation (Advanced
directives, 2014)
2. Durable Power of Attorney
● "A durable power of attorney is a legal
device that permits one individual, known as
a "principle", to give to another person
called the "attorney-in-fact", the authority to
act on his or her behalf" (Morrison, 2010)
● The attorney-in-fact that is appointed is
given the responsibility to take care of
banking, legal and real estate decision
making for a specified amount of time that
may be for a lifetime if needed. (Morrison,
2010)
● Issues with a durable power of attorney is
the appointed “attorney-in-fact is limited by
their own knowledge of legal matters and
finances, therefore leaving room for
possible errors. (Morrison, 2010)
3. Surrogate Decision Maker
A surrogate decision maker is an agent
who makes choices for a patient when the
person is unable to make them for
themselves.
A surrogate must follow the religious and
moral beliefs when making a choice for the
patient.
“Substituted judgment is a form of surrogate
decision making where the surrogate
attempts to establish what decision the
Group 5: Adlawan, Arceo, Desuyo, Eullaran, Lendio, Rubillar, Sison, Tegio
patient would have made if the patient were
competent to do so” (Morrison, 2010).
4. Guardianship
● Guardianship is a process where the court
system declares a patient incompetent for
decision making and a legal guardian is
appointed for managing financial, medical,
and living decisions.
5. Health Care Proxy
● Health Care Proxy is an appointed person
to make health treatment decisions if the
said person is unable to do so for
themselves.
LEGAL RIGHTS OF THE PATIENT
● The “Patient Self-Determination Act of
1990” protects the patients right to create an
advanced directive and the right to make
healthcare decisions including the right to
accept or refuse certain treatments.
(Morrison, 2010)
● “Health care institutions certified by
Medicare and/or Medicaid must take steps
to educate all adult patients and the larger
community on their right to accept or refuse
medical care. This law also directs facilities
to inquire on admission whether a patient
has made an advance directive, maintain
policies and procedures on advance
directives, and provide this information to
patients upon admission. Organizations
must comply with the PSDA in order to
receive reimbursement through the
Medicare and Medicaid programs'' (End of
life care, 2014)
ETHICAL ISSUES WITH ADVANCE DIRECTIVES
● Determining that a patient is incompetent to
make personal decisions is one of the first
issues when addressing advance directives.
Courts and medical personnel can assist in
the determination of competency to make
decisions.
● Ensuring that the patient has made their
wishes known and that others are
supportive of the patient's choices is a
second ethical hurdle when making life
choices . Making sure that when the patient
becomes unable to make choices the
advanced directive will be followed is a top
priority.
● When families do not agree with the
decisions that the patient or proxy have
made related to health care needs can
pose a large problem for both the patient,
healthcare providers and other family
members. (Lark & Gatti, 1999)
DNR OR END OF LIFE CARE PLAN
END OF LIFE CARE
is the term used to describe the support and
medical care given during the time surrounding
death. The goal of end-of-life care for dying patients
is to prevent or relieve suffering as much as
possible while respecting the patients’ desires
PALLIATIVE CARE
● is care to alleviate pain and manage
barriers to a good quality of life while
undergoing treatment for a serious illness.
● is available for all kinds of patients suffering
a life-limiting illness, regardless of their age,
condition or stage of illness.
● This is provided along with curative
treatment and may begin at the time of
diagnosis.
HOSPICE CARE
is a service for a person who has discontinued
disease-fighting treatments and is preparing to die.
This is primary for patients who have less than six
months left to live, and is tailored to assist them in
managing their pain and discomfort, while helping
their family transition and prepare for their end of
life provided in the home, assisted-living
residences, nursing homes, hospital. Hospice care
is provided in the home, assisted-living residences,
nursing homes, and hospital. Hospice care
provides terminally ill patients with extensive
physical, psychological, social, and spiritual care.
Although some hospice programs are housed in
inpatient facilities, the majority serve terminally ill
patients from the comforts and relaxed
circumstances of their own home. The hospice care
team's purpose is to assist the patient live as
complete a life as possible, with as little pain,
discomfort, and restriction as viable. It also
emphasizes the importance of a collaborative team
effort to assist the patient and family members in
overcoming the significant anxiety, dread, and
depression that accompany a terminal illness.
"The purpose of Hospice care is to provide support
and care for people in the final phase of terminal
disease so that they can live as fully and
comfortably as possible. Hospice affirms life and
regards dying as a normal process. Hospice
believes that through personalized services and
caring community, patients and families can attain
the necessary preparation for Death that is
satisfactory to them." - National Hospice
Organization, 2010)”
DNR
is commonly used for hospitalized patients with
advanced illness. A DNR order placed in a person’s
medical record by a doctor informs the medical staff
that cardiopulmonary resuscitation (CPR) should
not be attempted. This order has been useful in
preventing unnecessary and unwanted invasive
treatment at the end of life.
PROCEDURES USED TO RESUSCITATE:
​ Chest compressions:When a person's
heart stops beating, the heart is unable to
pump blood to the rest of the body, which
includes the brain and lungs. Pushing
frequently on the chest can assist keep
blood moving throughout the body until
heart function is restored.
​ almost always follow some of the same general
​ Intubation: A patient may be intubated if
breathing becomes difficult or impossible
due to disease or injury. An endotracheal
tube is inserted through the mouth and into
the airway. The tube is then hooked up to a
ventilator, which forces air into the lungs.
​ physician ordering an ambulance crew to
​ Cardioversion: Cardioversion is used to
treat irregular cardiac rhythms such as
arrhythmias and atrial fibrillation (also
known as AFib). This can be accomplished
through the use of a set of paddles to
administer an electrical shock to the heart or
through medicines.
​
​ IV medications: Medications that are
sometimes used in the case of cardiac
arrest include epinephrine, amiodarone,
vasopressin, and atropine sulfate. These
are "crash cart medications," so named
because they can be found on the wheeled
cart that medical professionals use during
an emergency resuscitation.
DNR ORDER RULES
The application of DNR orders varies from state to
state, especially regarding out-of-hospital (meaning
ambulance) care. Some states have standardized
forms for DNR orders; if the order is not written on
that specific form, it cannot be honored. Other
states are less regimented and honor any type of
clear DNR order.
Many states allow emergency responders to follow
DNR orders written to other care providers, even if
they aren't written on standardized forms. For
instance, in New York State, paramedics and
emergency medical technicians are usually allowed
to follow DNR orders written for the staff of a
nursing home.
They also may be able to honor orders written for
patients getting nursing care at home if the home
care nurse has a copy of the DNR order in hand.1
Each state is different, and municipalities may differ
within each state
Regardless of the format or the venue, DNR orders
rules; they have to in order to be valid. DNR orders
must:
● Be written by a doctor rather than
verbalized.9 There are exceptions to this
rule, such as an emergency medical service
withhold resuscitation via the radio or a
registered nurse taking an order from an
Group 5: Adlawan, Arceo, Desuyo, Eullaran, Lendio, Rubillar, Sison, Tegio
admitting doctor over the phone.1 Generally,
there are safeguards for these exceptions to
make sure the order is validated later.
● Be signed by a doctor. In those cases where
orders were taken by a nurse over the
phone, states usually set a deadline for the
doctor to physically verify and sign the
order.
● Include the patient's name as well as the
date. Depending on the state, orders may
expire after a certain amount of time or
there may be a deadline for the physician to
follow up. Even if a DNR order doesn't
expire, a particularly old order may prompt a
caregiver to revisit the decision
ETHICAL CONSIDERATIONS OF DNR ORDERS
The inconsistent application of DNR orders means
some patients get less than optimal care once
providers are aware of the presence of a DNR.
There still needs to be more study on this issue, but
some healthcare providers will even disregard
basic care to patients with DNR orders.
It's important to remember that a DNR order is not
an order to withhold all treatment for a patient, but
simply in order not to resuscitate a patient. The
definition of resuscitation can be complicated.
Some practitioners only withhold chest
compressions while still providing advanced care
like mechanical ventilation—at least until there is no
longer a pulse. Other healthcare providers will
withhold any advanced treatments from a patient
with a DNR order.
Because of these issues, for anything other than a
terminal diagnosis —like cancer or some end-stage
chronic conditions—getting a DNR order may not
be the right decision. Discuss the options with your
healthcare provider now rather than later, but don't
feel pressured to make up your mind about
end-of-life decisions. Keep in mind that if we're just
talking about withholding CPR, it may be better to
let rescuers attempt resuscitation during an
emergency. There is little chance that CPR out of
the hospital will be successful anyway, and the
ethical dilemma will be avoided.
NURSING DIAGNOSIS
● Compromised family coping-
● Activity intolerance
● Anticipatory grieving
NURSING CARE PLAN
The nursing care planning for end-of-life care
focuses on managing pain, avoiding or managing
problems, preserving quality of life as much as
feasible, and attempting to put plans in place to
fulfill the patient's and/or family's final wishes.
● Compromised family coping
a. Assess the level of anxiety present
in family and/or SO.
b. Determine the level of impairment of
perceptual, cognitive, and/or
physical abilities. Evaluate illness
and current behaviors that are
interfering with the care of the
patient
c. Note patient’s emotional and
behavioral responses resulting from
increasing weakness and
dependency
d. Discuss underlying reasons for
patient behaviors with family.
e. Determine current knowledge and/or
perception of the situation.
● Activity intolerance
a. Assess sleep patterns and note
changes in thought processes
behaviors.
b. Recommend scheduling activities for
periods when the patient has the
most energy. Adjust activities as
necessary, reducing intensity level
and/or discontinuing activities as
indicated.
c. Encourage patients to do whatever
possible: self-care, sit in a chair, visit
with family or friends.
d. Instruct patient, family, and/or
caregiver in energy conservation
techniques. Stress necessity of
allowing for frequent rest periods
following activities.
e. Monitor breath sounds. Note feelings
of panic or air hunger.
 ● Anticipatory grieving
a. Facilitate development of a trusting
relationship with patients and/or
family.
b. Assess patients and/or SO for the
stage of grief currently being
experienced. Explain the process as
appropriate.
c. Provide an open, nonjudgmental
environment. Use therapeutic
communication skills of active
listening, affirmation, and so on.
d. Be aware of mood swings, hostility,
and other acting-out behavior. Set
limits on inappropriate behavior,
redirect negative thinking.
e. Monitor for signs of debilitating
depression, statements of
hopelessness, desire to “end it now.”
Ask patient direct questions about
state of mind.

NURSING RESPONSIBILITIES
● Assessing for pain and other distressing
symptoms and providing evidence-based
interventions to alleviate them.
● Preventing initiation of interventions that may not
improve comfort and quality of life.
● Work with team members to attend to the
psychological and spiritual dimensions of terminal
illness
● Work with family members as they also shift their
focus from curing the patient to palliative care
● Commitment to family members after the patient's
death, with support and referral for counseling, if
indicated.
● Provide compassionate and sensitive end of life
care with the support of the wider multidisciplinary
team