 NCM 106 – HEALTH CARE ETHICS

JENNIFER J. VALERO, MAN-RN

CLINICAL INSTRUCTOR
 SEMIFINALS PERIOD
“Life is pleasant. Death is peaceful. It's the
transition that's troublesome.”
(by: Isaac Asimov)
“Human life is something sacred and taking a
life is very wrong.”
“Birth is a miracle. Death is a mystery.
Neither fit easily into a biomedical model”.
 SUMMARY OF TOPICS FOR SEMIFINALS
 Dignity in Death and Dying
 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
 B. Ethical decision-making process
 Bioethics and Research
 A. Principles of Ethics in Research
- Nuremberg Code, Declaration of Helsinki (DoH) & Belmont Report
 DIGNITY IN DEATH
& DYING AND EOL
 INTRODUCTION
Issues that surround the end of life become increasingly complex
as our medical treatments improve. Almost 85% of all deaths in the
U.S. occur in a facility such as a hospital, nursing home, or hospice. In
70% of these cases life prolonging treatments are opted to be
withheld.
 During this two-week topics, we will examine the ethical issues that
need to be addressed near the end of life (EOL).
E.g. Technology makes it possible to maintain bodily functions,
while ethics addresses questions concerning both the quantity
and the quality of life.
 SHARING:
 Are you afraid of death?
 What makes death a unique event?
 Simple recall of concepts: What are the steps in
the normal grieving process?
 What are your thoughts on these?
 INTRODUCTION
 Of all the problems that can be considered life and death
ethics, none causes more moral anguish than the end of life
issues of;
a. withholding/withdrawing life support
b. euthanasia
c. assisted suicide
 The health care practitioner’s duty to respect life and preserve
it as much as possible, may at times come into direct conflict
with the duty to alleviate pain and suffering.
DYING
• The last stage of life; a process that from a medical point of
view begins when a person has a disorder that is untreatable
and inevitably ends in DEATH, or the final stages of a fatal
disease.
• Dying is a process, whereas death is an event. The essential
task of the dying person is to work through psychologic response
toward the reality of approaching death to a final and peaceful
acceptance of that reality.
 NURSING RESPONSIBILITIES IN
DEATH & DYING
 PROLONGATION OF LIFE
The decision to preserve biological life at any cost leads to
immense personal and social tragedies that consume
individuals, human energies, and scarce resources - for no
seeming good.
 Prolongation of Life- life support gadgets like defibrillators,
pacemakers, mechanical ventilators, potent pain relievers like
morphine and other narcotic analgesics, etc…
 The question then, is, what is to be done when all individual
personality is permanently lost and all we can sustain is biological
life?
 WHAT IS EUTHANASIA?
 WHAT IS EUTHANASIA?
• Euthanasia - is when a doctor gives someone who is
dying medication that will end their life.
• Some use the terms: “assisted suicide, physician-
assisted death, physician-assisted suicide, and mercy
killing” as synonyms for euthanasia.
• But legal and medical experts define these differently.
What is Assisted Suicide?
• Assisted suicide is when ill people kill themselves with someone else’s
help. There are many different ways that a person might help with a
suicide, but assisted suicide is generally defined as follows:
• The person who wants to commit suicide has asked for help.
• The person knows that what they are asking will cause death.
• The person assisting knows what they’re doing. They intentionally help.
• The person assisting provides medication to the person committing
suicide.
• The persons who want to die takes the drugs themselves.
What is Assisted Suicide?
• In physician-assisted suicide, a doctor provides medication to the
person who wants to die. The doctor may also give instructions on how
to take the medication so it will cause death. But the doctor does not
inject the medication or even help the sick person swallow a drug.
• Many Americans seem to support laws allowing physician-assisted
suicide. In a poll of 1,024 Americans, 72% of people said doctors
should be able to help someone with an incurable disease end their life
if they wish to.
• If a doctor or anyone else actually gives the person the lethal
medication, the act is considered euthanasia. This can be a crime even
in areas with assisted-suicide laws.
 BRAIN DEATH
 One essential differentiation among patient types is between those
who have suffered brain death and those who are in a persistent
vegetative state( PVS).
 Criteria for brain death given by the Harvard Medical School of Ad
Hoc Committee;
a. Unreceptivity and unresponsiveness
b. No movements or breathing
c. No reflexes
d. Flat EEG of confirmatory value(detects electrical activity of the brain)
 INVIOLABILITY OF HUMAN LIFE
The inviolability of the person which is a reflection of the
absolute inviolability of God, finds its primary and fundamental
expression in the inviolability of human life. Above all, the
common outcry, which is justly made on behalf of human rights-
for example, the right to health, to home, to work, to family, to
culture - is false and illusory if the right to life, the most basic
and fundamental right and the condition for all other personal
rights, is not defended with maximum determination.
- Pope John Paul II, Christifideles Laici (1988), no. 38
 DEFINITION OF TERMS
• SUICIDE
- is defined as death caused by self-directed injurious behavior
with intent to die as a result of the behavior.
•DYSTHANASIA
- an undignified and painful death due to
inadequate control of symptoms. It is the term for futile or
useless treatment, which does not benefit a terminal patient.
DEFINITION OF TERMS
 ORTHOTHANASIA
- The word was used for the first time in the 1950’s. It means
correct dying, or allowing to die or letting die. In the case of letting
die, what is directly intended is the relief of the acute pain of the
patient. In allowing to or letting die, therefore, death is neither
directly caused nor intended or postponed. It merely happens. It
is an event, part of the temporal life of every human being.
-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.
Administration of Drugs to the Dying
Patients perceive pain differently, depending partly on whether other
factors (eg, fatigue, insomnia, anxiety, depression, nausea) are
present. Analgesic choice depends largely on pain intensity and
cause, which can be determined only by talking with and observing
patients. Patients and physicians must recognize that all pain can be
relieved by an appropriately potent drug at sufficient dosage,
although aggressive treatment may also cause sedation or
confusion.
 Commonly used drugs are aspirin, acetaminophen, or nonsteroidal
anti-inflammatory drugs (NSAIDS) for mild pain; oxycodone for
ADVANCE DIRECTIVES
 Health care advance directives are legal documents that
communicate a person's wishes about health care decisions in
the event the person becomes incapable of making health care
decisions.
Two basic kinds of advance directives: living wills and health
care powers of attorney.
 a written statement of a person's wishes regarding medical
treatment made to ensure those wishes are carried out should
the person be unable to communicate them to a doctor.
DO NOT RESUSCITATE (DNR) or EOL CARE PLAN
- A DO-NOT-Resuscitate (DNR) order, is a medical order written
by a doctor. It instructs health care providers not to do
cardiopulmonary resuscitation (CPR) if a patient's breathing
stops or if the patient's heart stops beating.
- CPR and Advanced Cardiac Life Support (ACLS) , and
interventions that could theoretically be offered to all patients
within the hospital. By the 1970s, it became obvious that it was
not in the best interest of certain patient groups to be
resuscitated, and hospitals began to initiate policies governing
DNR orders.
 LANGUAGE OF DNR
 DNR GUIDELINES
1. DNR orders should be documented in the written medical record.
2. DNR orders should specify the exact nature of the treatments to
be withheld.
3. Patients when they are able, should participate in DNR decisions.
Their involvement and wishes should be documented in the
medical record.
4. Decisions to withhold CPR should be discussed th the health care
team.
5. DNR status should be reviewed on a regular basis.
PROXY DECISION-MAKING STANDARDS
The courts have not made their decisions on the basis of personhood
criteria but rather have created standards for the allowance of decision
by proxy.
1. Doctrine of parens patriae - if a patient was never in a position to
formulate a decision regarding acceptance or refusal of care, often the
physician, hospital, or a family member may seek resolution of the
problem m the courts prior to implementing a decision.
2. Best-interest standard - “Health is better than illness” or “Life is better
than death.” e.g. In cases in which children have been denied life-
preserving care by their parents, the state has often overturned the
parental decisions based on the best-interest standard.
3. Substituted-judgment standard - maintains that the
decision about treatment or non-treatment must remain
that of the patient, based on the principle of autonomy.The
fact that a previously competent patient becomes
incompetent to make a decision for himself does not take
from him the right to self-determination.
 A SUBSTITUTE is selected who is required to act in
proxy for the patient - that is, to make the decision that
the incompetent patient would have made if the patient
had remained competent.
Sharing of Insights/Assignment:
Discuss the arguments against the adoption of active
euthanasia as a practice of modern health care
according to;
a. religious standpoint
b. non-religious standpoint
 REFERENCES
• https://www.slideshare.net/AmboIsland/bioethics-dignity-in-death-and-dying
• https://www.slideshare.net/ghaiath/death-dying-and-end-of-life
• https://www.slideshare.net/maryamyasser372/euthanasia-ppt-55774612
•
https://www.oclarim.com.mo/en/2017/06/09/life-matters-4-orthothanasia-or-allowing
-to-die/
https://www.merckmanuals.com/professional/special-subjects/the-dying-
patient/symptom-relief-for-the-dying-patient
https://www.verywellmind.com/five-stages-of-grief-4175361
https://medicine.missouri.edu/centers-institutes-labs/health-ethics/faq/