Lecture N5

The end of life. The definition of death. Philosophical

definitions of death. Brain death. Public confusion and
disagreement. About the definition and criterion of
death. Defining death in other cultures.
 The end of Life

 A person was dead when he/she no longer breath and no longer had a
heartbeat.

 Currently high-tech machines can keep a person “alive” when they are no
longer able to breathe on their own and their heart will not work without
assistance.
 Criteria
 Standardsof the cognitive criteria - personhood can end before the
human body actually dies (e.g. advanced dementia).

 Standards of defining a person as a human being with a full set of

unique DNA – a person with no brain function who is kept alive on a
ventilator is not considered dead.

 Combining brain death with cessation of cardiopulmonary activity is

the medical and legal definition of death.

 After the death the person’s rights and principles of bioethics end,
begin the rights of the deceased.
Heart and Lung Function and Death
 Until 1960 - medical definition of death was cessation of heart-lung
function.

 Technological development:
 In 1953 (Denmark) – creation of intensive care units (Dr. Bjorn Ibsen);
assistance in breathing, kidney function, heart function, blood pressure
stability, and nutrition and hydration.
 Mechanical ventilators, or artificial respiration (body and brain
oxygenation)
 Organ transplantation

 Heart transplantation in 1967

Three main medical/ethical standards of Brain Death
 Harvard Criteria (1968) – very conservative; “If you’re Harvard dead,
you’re really dead.” /Harvard Medical School Ad Hoc Committee/

 The patient is unreceptive and unresponsive.

 There is no movements or breathing except for spinal reflexes.
 No brainstem reflexes can be observed, including pupillary signs, such as fixed,
midsize pupils and no movement of the eyes when the head is turned. No facial
expression response to pain is observed, and the gag and cough reflexes are not
observed.
 Apnea, or the suspension of breath, is observed and tested, by disconnecting the
ventilator, delivering oxygen, observation, then measuring levels of blood pH
and Paco2 levels.
 Conditions such as drug intoxication and hypothermia must be excluded as a
 Uncertain situation
 Tests can be repeated 6 to 24 hours later. If the results are
the same, the patient can be declared dead.

 When brain function has ended, doctors must determine

that this condition is irreversible. An electroencephalogram
(EEG) may be given to test for the existence of brain waves,
but this is not necessary if all other criteria are present.
 Unified Declaration of Death Act

 In 1981 a presidential commission issued a report that created

and endorsed a model statute called the Uniform Determination
of Death Act (UDDA)
“An individual who has sustained either (1) irreversible cessation
of circulatory and respiratory functions, or (2) irreversible
cessation of all functions of the entire brain, including the brain
stem, is dead. A determination of death must be made in
accordance with accepted medical standards.”
 Working Brain

 The human brain has three regions with three different functions:

 The cerebrum is called the higher brain because it controls

consciousness, reasoning, memory, feelings, and thought. This is known
as higher brain function.

 The cerebellum controls movement and balance.

 The brain stem is called the lower brain because it controls essential
functions such as breathing, swallowing, and sleep.
 Types of Brain Death
 Brain death is divided into two categories:

 Whole brain death – all three regions of the brain (cerebrum, cerebellum,
and brain stem) have stopped functioning. Whole brain death is the criteria
used in the UDDA.

 Higher brain death – cerebrum, or higher brain, is dead, that person is no

longer conscious, cannot anticipate pain or pleasure, and cannot think or
reason, but may still breathe, have some limited movement, and go through
sleep and wake cycles (the cognitive criterion standard of brain death). The
condition is called a persistent vegetative state, or PVS.
Three main medical/ethical standards of Brain Death
 Harvard criteria:

 No one declared dead by these criteria has ever regained consciousness.

 If you’re Harvard dead, you’re really dead.”

Three main medical/ethical standards of Brain Death
 Cognitive criterion (definition of personhood):

 A person must have five capacities - reasoning, self-awareness,

communication, agency, and consciousness of the external world to be alive.

 A person with an advanced neurologic disorder, such as end stage

Alzheimer’s disease, could be classified as dead.
Three main medical/ethical standards of Brain Death

 Irreversibility standard

 Irreversibility standard – death occurs when unconsciousness is

irreversible. This places a burden on the treating physician to make this
judgment and then guide the family.
 Declaring a Patient Brain Dead

 A doctor can legally and ethically declare someone dead without the
family’s consent.

 Physician-relatives communication.
 Life vs Death

 Quality-adjusted life years (QALY) numbers for quality

of life can be less than zero (sometimes living can be
worse than death)

 The Right to Die movement claims the concept of dying

with dignity. This movement is grounded in the
principle of autonomy
 Case of Karen Ann Quinlan
In 1975, Karen Ann Quinlan was a healthy 21-year-old who fell into a coma
after excessive alcohol and drug use. After 16 months on life support with
no improvement, Karen’s parents went to court to have her taken off the
respirator. Her doctors and the administrator of the Catholic hospital
disagreed with this plan.

The court ruled that her father, as her guardian, and based on the right to
privacy, could let an incompetent patient die by removing life support. The
Quinlans were able to recall two times when Karen said she would not want
to be kept alive on machines, and that met the standard for respecting the
patient’s autonomy. Karen was weaned from the ventilator, but because
nutritional support, at that time not considered artificial life support, wasn’t
removed, she lived for 10 more years.
 Case of Nancy Cruzan

In 1983, Nancy Cruzan was a 24-year-old with anoxic brain injury after a
car accident. She remained in PVS for seven years. At that point, her parents
wanted her feeding tube removed. Nancy had no living will and the family
couldn’t present evidence of what her wishes would be, so the state court
turned down the request, ruling that the state has an interest in preserving
life regardless of the quality of life. The case was appealed to the Supreme
Court.
 Three Important Declarations

 A competent patient has the right to decline medical treatment even if it

leads to death.

 Withdrawing a feeding tube isn’t different from withdrawing other types

of life support.

 For incompetent patients, states may pass a law requiring that clear and
convincing evidence of what a patient would have wanted be presented
before life support is withdrawn.
 Principle of Proportionality
 Continuing medical intervention can harm a patient by keeping them alive.

 One ethical criteria doctors use to decide if life support should be

continued if to ask if the burden of providing mechanical life support
outweighs the benefit to the patient.
 Conditions for Ethically End Life Support

 Beyond a reasonable doubt that no medical goals other than simply

keeping the patient alive can be met.

 The patient cannot express wishes or preferences.

 Quality of life falls consistently below the minimum standard.

 The family agrees that life support can be withdrawn.

 Withdrawing Life-Sustaining Treatment
 Life-sustaining treatment is any drug, procedure, or surgery that extends life
without curing the disease or condition

• Artificial nutrition, such as tube feeding

• Artificial hydration
• Mechanical ventilation
• Blood transfusion
• Renal dialysis
• Antibiotics
• Chemotherapy
 Weighing the Benefits
 Medical futility - a judgment that further medical treatment would
have no useful result.

 Questions under discussion:

 Will this treatment make a difference in the patient’s condition?

 Do the benefits of treatment outweigh the burdens?
 Is the treatment distressful or burdensome for the patient or family?
 Is there any hope for recovery?
 If the patient can improve, what will his life be like?
 Family Counseling
 Making decisions about withdrawing treatment, beginning terminal
sedation, and issuing DNR (do-not-resuscitate) orders are the most
difficult anyone can make.

 When the family disagrees with a patient’s end-of-life decisions, and

those decisions are outlined in an advance directive, healthcare
providers are obligated to follow the patient’s wishes, in accordance
with the principle of autonomy.

 Ifthere is no advance directive, the family members who object to

withdrawing life-sustaining treatment have often prevailed.
 Euthanasia and Physician-Assisted Suicide
 Euthanasia, or mercy-killing - ending a life deliberately to relieve
intractable suffering.
 Proponents of euthanasia - a death filled with suffering is a wrongful
or bad death and that euthanasia should be legal.
 Opponents of euthanasia - any deliberate effort to cause death is
wrong.
 Physician-assisted suicide (PAS) - a form of euthanasia where a doctor
physically helps someone kill themselves.
Euthanasia vs Physician-Assisted Suicide
 The AMA (the American Medical Association) states that if a
medical practitioner acts in accordance with good medical practice,
the following forms of management at the end of life don’t
constitute euthanasia or physician-assisted suicide:

 Not initiating life-prolonging measures

 Not continuing life-prolonging measures
 The administration of treatment or other action intended to relieve
symptoms which may have a secondary consequence of hastening
death
 Mercy-Killing
 Euthanasia – Greek “good health”:

 Voluntary (with consent of the patient)

 Involuntary (without consent of the patient)
 Non-voluntary (patient unable to give consent).
 A Doctor’s aid in Death
In 1994, the state of Oregon passed the Death with Dignity law, which took
effect in 1997. Doctors in that state can prescribe drugs to help their terminally
ill patients commit suicide. The patients themselves administer the drugs.
Prescribing lethal drugs is tightly controlled. These controls include:

 The patient must be 18 years or older and a resident of Oregon.

 The patient must have capacity to make healthcare decisions and have
expressed his or her wish to die.
 The decision must be made with informed consent. The patient must be told
of her diagnosis, prognosis, risks of the drugs, the probable result of using the
drugs, and alternatives.
 The patient’s diagnosis and prognosis must be confirmed by a consulting
doctor. The primary care physician might also request a psychiatric evaluation.
End of life considerations

 Mr. AB, a 21-year-old patient in the care of the General Hospital, has been in
a persistent vegetative state (PVS) for three and a half years, subsequent to a
severe crushed chest injury that caused catastrophic and irreversible damage
to the higher functions of his brain. In this condition, the brain stem remains
alive and functioning, while the brain cortex loses its ability to function.
Although he continued to breathe unaided and his digestion continued to
function, he could not see, hear, taste, smell, speak or communicate in any
way, was incapable of involuntary movement, could not feel pain, and had no
cognitive function. He was being fed artificially and mechanically by a
nasogastric tube that had been inserted through his nose into his stomach.
End of life considerations

 Dr. K examined Mr. AB and testified that this was the most severe case he had
ever seen. He went on to say that Mr. AB was likely to survive for a few years,
though no more than five, mainly due to his high risk of developing infections.
The unanimous opinion of all the doctors who had examined him was that
there was no hope whatsoever of recovery or of any kind of improvement in
his condition. Mr. AB gave no clear indication of his views prior to his injury,
and his family was unable to consent on his behalf. Based upon their
knowledge of their son, his parents said he would not have wished to continue
in his present condition.
End of life considerations

 Under these circumstances, the hospital’s geriatric consultant reached the

clear conclusion that further treatment should be withheld. This would
involve discontinuing artificial feeding through the nasogastric tube and
withholding antibiotic treatment if and when infection appeared. If this
course were to be adopted, within 10 to 14 days the physical functioning of
Mr. AB’s body would come to an end, and he would die of starvation. This
process would be unpleasant for those observing, but Mr. AB himself would be
totally unaware of what was taking place.
 Is starvation the proper way to hasten Mr. AB’s death?
Pain relief

 Mrs. GC is a 28-year-old prison inmate. She was approximately seven months

pregnant when she gave birth to her child. Prior to the delivery, Mrs. GC was
transferred from the Correctional Facility for Women to the Medical and
Classification Center (MCC) to facilitate closer monitoring of her pregnancy.
Mrs. GC had five prior pregnancies, most of which were pre-term deliveries.
This fact was documented in the MCC records. At approximately 7:00 p.m.,
Mrs. GC began bleeding and felt severe pain in her lower abdomen; she went
to the Health Services and was seen by Nurse R. Without taking Mrs. GC’s vital
signs, performing a vaginal examination, or attempting to monitor the baby’s
heart tones, Nurse R sent Mrs. GC back to her living unit and told her to
return when the contractions were six to seven minutes apart.
Pain relief

 At approximately 9:30 p.m., Mrs. GC’s pain worsened. She returned to Health
Services and reported to Nurse R that she was still bleeding with severe pain
in her abdomen, and her contractions were six minutes apart. Nurse R placed
her hands on the exterior of Mrs. GC’s abdomen and noted that she was
unable to feel any contractions. Nurse R monitored the baby’s heart tones,
which were 142 beats per minute. Despite concluding that Mrs. GC was in
‘possible early labor’, Nurse R sent her back to her living unit and instructed
her to return to Health Services only if the bleeding increased or the
contractions intensified in severity or regularity.
Pain relief

 Following Nurse R’s instructions, Mrs. GC returned to her living unit. She sat
on the edge of her bed, her pain mounting, until 11:25 p.m., when she began
to scream from the intense pain and moved to the cement floor, where she
lay in a fetal position. At approximately 11:45 p.m., Mrs. GC was transported
from MCC to the hospital. Shortly after arriving at the hospital, she delivered
a premature baby boy at 12:20 a.m. Neither Mrs. GC nor the baby suffered
any complications during the delivery. The baby was later released from the
hospital to the care of Mrs. GC’s mother.
 Based upon Mrs. GC’s pain and suffering, should Nurse R have acted
differently?
Right of refusal

 HA is confined to a correctional services medical facility, where he is serving a

life term. On May 24, 1991, while he was in prison, HA jumped or fell off a
wall. As a result, he fractured a cervical vertebra, rendering him
quadriplegic. He lacks any physical sensation or bodily control below the
shoulders. HA suffers from a profoundly disabling and irreversible physical
condition. Medical personnel must assist him with all bodily functions, and HA
must cooperate with them when he is being fed and given medication. His
condition not only makes him fully dependent on others for all bodily
functions, but also renders him susceptible to illness and infection that
require further medical attention.
Right of refusal

 Since October 11, 1991, HA has intermittently refused to be fed, causing

severe weight loss and threatening his health. He has also refused necessary
medication and treatment for his general care. Consequently, he is at
substantial risk of death from possible pulmonary emboli, starvation,
infection, and renal failure. Staff psychiatrists have examined HA and found
him depressed about his quadriplegic condition, but mentally competent to
understand and appreciate his circumstances. Dr. T, a staff member of the
correctional services medical facility, who is the attending physician for HA,
would like to give HA life-sustaining treatment.
 Should the physician force HA to get life-sustaining treatment?
End of life

 Mrs. SR is a 42-year-old married woman who is the mother of an 8 1/2-year-

old son. Mrs. SR suffers from amyotrophic lateral sclerosis (ALS), commonly
known as Lou Gehrig’s disease. Her life expectancy is between 2 and 14
months, and her condition is rapidly deteriorating. Very soon she will lose the
ability to swallow, speak, walk, and move her body without assistance.
Thereafter she will be confined to her bed, unable to breathe without a
respirator and unable to eat unless a gastrostomy tube is inserted into her
stomach. Mrs. SR understands her condition. She is aware of the trajectory of
her illness and the inevitability of her death. Her wish is to control the
circumstances, timing, and manner in which she dies.
End of life

 Mrs. SR does not wish to die so long as she still has the capacity to enjoy life.
However, by the time she no longer is able to enjoy life, she will be physically
unable to terminate her life without assistance. Mrs. SR wants a qualified
medical practitioner to be allowed to install the technological means by
which she can end her own life at the time of her choosing.
 Should a medical practitioner be allowed to facilitate Ms. SR’s wish to
determine the time of her death?
Treatment of minors – Medical
treatment of teenagers
 In December 1980, a government body issued guidelines on family planning
services for young people. These guidelines stated or implied that, at least in
certain cases which were described as ‘exceptional’, a doctor could lawfully
prescribe contraception for a girl under the age of 16 without her parents’
consent.
Treatment of minors – Medical
treatment of teenagers
 The guidelines further stated that a doctor should proceed on the assumption
that advice and treatment on contraception should not be given to a girl
under the age of 16 without parental consent, and that the doctor should try
to persuade the girl to involve her parents in the matter. Nevertheless, the
principle of confidentiality between doctor and patient applies to girls under
16 seeking contraceptives. Therefore, in exceptional cases a doctor can
prescribe contraceptives without consulting the girl’s parents or obtaining
their consent if, in the doctor’s clinical judgment, prescribing contraceptives
is desirable.
Treatment of minors – Medical
treatment of teenagers
 Mrs. G, the mother of five daughters under the age of 16, objected to the
guidelines and sought assurance from her local area health authority that her
daughters would not be given advice or treatment regarding contraception
without her prior knowledge and consent while they were under the age of
16.

 Can a doctor ever, under any circumstances, lawfully give contraceptive

advice or treatment to a girl under the age of 16 without her parents’
consent?
Thank You for Attention!