DIGNITY IN DEATH AND DYING

EUTHANASIA – comes from Greek word “eu” (good) and “Thanatos” (death)
 It is an act or practice of killing or permitting the death of hopelessly sick or injured individuals (such as persons or
domestic animals) in a relatively painless way for reasons of mercy (Merriam Webster)
 Also known as “mercy killing” and “assisted suicide”; Practice is illegal in the Philippines
 Allow a patient to experience a relatively “good death”, rather than a slow, painful or undignified death
Types of Euthanasia:
Types Description
Active euthanasia Killing by active means, for example injecting with a lethal dose of a drug
(aggressive euthanasia)
Passive euthanasia Intentionally letting a patient to die by withholding artificial life support such as a
ventilator or feeding tube
a. Withholding – not to administer a lifesaving medical treatment
b. Withdrawal – patient is removed from a life support
Voluntary euthanasia With the consent of the patient
Involuntary euthanasia Without the consent of the patient, for example, unconscious and his/her wishes
are unknown
a. Involuntary – against the patient’s wishes
b. Non-voluntary – without the patient’s consent but wishes are unknown
Self-administered The patient administers the means of death
“Other” administered A person other than the patient administers the means of death
euthanasia
Assisted euthanasia Patient administers with the assistance of another person such as the physician

DYSTHANASIA – a term used when a person is kept alive artificially, in a condition where otherwise they cannot
survive, sometimes for some sort of ulterior motive
 Occurs when a person who is dying has their biological life extended through technological means without regard
to the person’s quality of life
 Technologies such as implantable cardioverter defibrillator and artificial ventilation can extend the dying process
 CPR can be considered as a form of dysthanasia

SOCIAL EUTHANASIA or MISTHANASIA – miserable death which does not give a good, smooth and painless
death
Common Examples:
a. The default of structural assistance, where the absence or precariousness of medical care services ensures that
people with physical or mental disabilities or with diseases that could be treated die early, live in pain and suffering,
in principle. is avoidable
b. Malpractice – a medical error where patient suffer, for example, with delayed diagnosis or lack of the correct
forms of analgesia
 Another Example: removal of a vital organ for transplantation before the donor has died
c. Negligent misthanasia – occurs when there is omission of relief when the physician-patient relationship has
already been established or the patient is abandoned

ORTHOTHANASIA – (art of dying well) seeks to deal with the patient helping him face his destiny with greater
tranquility, maintain a distinction between healing and caring, between maintaining life and allowing the person to
die, when the time comes.

EUTHANASIA and SUICIDE

Suicide – is the intentional termination of one’s own life
 Includes cases whether the person does this by omitting something (passive suicide) or by doing something
(active suicide)

Ethics of the Patient: attempt to answer these two basic questions …

1. Is refusing treatment suicide?
  In medical ethics – the patient or surrogate may intend the patient’s death, not because he/she wants to die, but
because of the medical condition or the treatment for it is intolerable. They intend their death because of the
inhumaneness of their circumstances. The real issue (what is intended), is the elimination of suffering, and the
means is perhaps discontinuing ventilation. Given a life without suffering, the patient would prefer to be alive.
2. Is suicide unethical?
 1st argument: religious and theological – holds that our lives belong to God and are merely loaned to us, so we
have no right to dispose of our own lives, even though we have the right to use them within limits.
 2nd argument: holds that human life is so precious that to act against it is to act against the greatest of all
human goods, or at least against the good on which all other human goods depend
o For example: life is experienced in a vegetable existence or life can be so painful and crushing that it renders
all other goods impossible – emphasize on the ethical principle that a patient is not required to use
extraordinary means to continue existence
 3rd argument: consequentialist. Condemns suicide because it harms the community – consider the impact of
suicide on the society – suicide is wrong because it has harmful consequences for other individuals

Health Care Providers and the Ethics of Suicide Prevention:

(Points related to Suicide Prevention)
 Society has a clear interest in the preservation of life – life has a fundamental value, and an important advantage
to living in society is the protection of life
 The value of the individual is not purely and simply his/her value to society, most individuals are valuable to
society, and society has a legitimate interest in preserving most of its citizens.
 Suicide do affect the rights of others: for example – if a child claims that food and shelter are not met because of
suicide, society will be burdened with the child’s support – therefore, suicide is a crime
 Health care professionals need to be insulated from the active suicide to protect the functioning of the profession

Health Care Providers and the Ethics of the Death of a Patient

 Question 1: Is it ethical for the health care provider to cooperate when a competent patient refuses treatment?
 Question 2: May a health care provide cooperate with a patient’s active suicide?
 Cooperation means that the competent patient has asked for or consented to the cooperation
 Incompetent or doubtfully competent patient or surrogate consent leads to a more delicate problem.
 Health care providers are protected by law if the patient refuse treatment or demand for the withdrawal of life-
sustaining treatment
 Emotional problems may arise in admitting defeat, but no ethical problems
 Ethical to omit treatment: When a patient is terminal but death is not imminent (when the disease or injury
progress slowly), and granted the consent – on the ground that nothing can be accomplished in thwarting the
progress of the disease
 Unethical to omit care: since human dignity is to respected

Reasons For Not Starting Or Stopping Treatment In The Case Of A Consenting Patient Who Is Terminally Ill
(Ethical):
1. Health care provider has no obligation to prolong dying merely for the sake of prolonging it – meaning, no sense to
prolong life when it leads to prolonging the dying process
2. When treatment is only prolonging the agony of the patient – becomes unethical as an insult to human dignity
3. When there is severe shortage of medical resources (except when the patient insists or surrogate objects)
 Obligation of care provider that every ethical effort be made to alleviate these suffering with drugs and other
methods

FEEDING and HYDRATION: Is it medically indicated for the terminally IIl? – Circumstances wherein withdrawal
of the treatment is acceptable:
1. The procedure are futile – unlikely to achieve any purpose
o Would not be helpful to the patient even if procedure is successful
o Burden outweighs the benefit
Examples of futile Treatment:
o Has burns over most of his body and severe blood clotting deficiency is impossible to control bleeding
o Patient with severe congestive heart failure with CA of the stomach which delivers food through the intestines
2. No possibility of benefit to the patient – permanently lost consciousness
3. Hydration/feeding impose disproportionate burden
COOPERATION WITH REFUSAL OF TREATMENT BY A NONTERMINAL PATIENT
 This occurs when the patient judges that it is not worthwhile living on a respirator or being fed artificially for years
– patient chooses not to live further
 Regardless of the medical indication from the health care provider , the patient retains the right to refuse
treatment
 Only a court order or court-appointed guardian has the right to overrule
 Health care providers can ethically refuse to cooperate in situations like patient refusing medically indicated
procedures but asks to be made comfortable while in the hospital.

PHYSICIAN INITIATIVES
 The physician is obliged to inform the patient clearly and completely about his condition in order to obtain consent
for treatment
 Information include accurate description of the burdens and benefits of continued treatment and the odds of
success
 Also obligated to provide treatment that does not harm the patient
 DNR (Do Not Resuscitate) – a written order not to attempt resuscitation in cases of cardiac arrest – correct when
(from a medical point of view), more harm than good will be done – no code order is ethical if the conditions and
consent are met
 Slow code – used to give families the impression that everything is barely done for the patient in situations in
which most of the time a no-code order would medically and ethically justified – occurs when family insists against all
reasons, the patient be kept alive, even when the patient is brain dead
o Also used while waiting for a relative to arrive to enter into farewells and grieving process.
 Partial code – written order to omit some medical interventions, but to employ other interventions

CARE FOR THE DYING

 DNR, no code, slow code stress omitting a treatment, but still there is a need for HUMANLY INTENSIVE CARE.
 Dying patient needs support of staff, family and friends
 Limit in visits is removed
 Children are allowed to visit
 Long-absent relatives can be encouraged to come for reconciliation

PAIN CONTROL
 A dying patient’s dependence on pain relief is due to the persistence of the pain, not to addiction.
 The patient still should be kept comfortable, particularly when that is her request

TERMINAL PATIENT – one whose condition will lead to death within a year, or who is irreversibly comatose, or
when there is a medical judgment that efforts, including resuscitation, would only prolong the dying process

ETHICAL PROBLEMS OF DEATH and DYING

Advance Directives include:

1. Living wills – written documents that direct treatment in accordance with the patient’s wishes in the event of
terminal illness or condition
a. Patient is able to declare which medical procedure he wants or does not want
b. Often difficult to interpret and not clinical specific in unforeseen circumstances
2. Health Care Proxies Or Durable Power Of Attorney For Health Care – (DPAHC) a legal document that
designates a person or people of one’s choosing to make decisions on his/her own behalf according to the patient’s
wishes

DIFFICULT DECISION IN END-OF-LIFE CARE

 Nurses have their own morals. Values and beliefs, which sometimes do not correspond with the patient’s values,
beliefs or wishes, causing internal conflict for the nurse.
 Regardless of the intervention or treatment, the nurse should focus on helping the patient weigh the benefits and
burdens of the intervention, rather than on the intervention itself.
1. Withholding/withdrawing of Medical Interventions
 Dilemma relate to the cessation of medical interventions
 Rationale: based on the fact that the burdens are outweighing any benefits the patient may get from it
 Advanced directives – documents that enable patients to make their decisions about medical care known to
their family and health care providers, in the event that they are unable to make those decisions themselves
 Benefits of withholding/withdrawing:
o Alleviate the burden of not wanting a particular intervention done
o Help prevent initiation of some sustaining treatments beforehand, where decisions are not needed.
o Help reduce overall cost of futile medical care

2. Do Not Attempt Resuscitation (DNAR) - the patient has elected cardiopulmonary resuscitation (CPR) to not be
initiated or administered in the event of a cardiac arrest

3. Allow Natural Death (AND) – allows patient to remain comfortable while not interfering with the natural process
of dying

4. Medical Order for Life Sustaining Treatment MOLST) – also referred to as Physician Order To Life-
Sustaining Treatment (POLST) and advanced directive to improve the communication of a patient’s wishes among
healthcare providers in the clinical setting.

HASTENING DEATH (Principle of double Effect) – refers to decisions that produce both desirable and undesirable
effects
 Example: a medication will reduce pain but further reduce respiratory rate that may cause death
 Nurse or physician should always consider the intended effect of the intervention.

TERMINAL/PALLIATIVE SEDATION – intervention used at the end of life, usually as a last effort to relieve suffering
 Involves sedating the patient to a point in which refractory symptoms are controlled – intent is to relieve suffering
 Criteria Required for Palliative Sedation:
o Terminal illness
o Severe symptoms not responsive to treatment and intolerable to the patient
o A DNR order in effect
o Death is imminent (hours to dying)

ASSISTED DYING – action in which an individual’s death is intentionally hastened by the administration of a drug or
other lethal substances
a. Assisted euthanasia – patient is provided with the means to carry out suicide – providing lethal dose of a
medication
b. Active euthanasia – someone other than the patient carries out the action ending the patient’s life
 Nurse’s organizations prohibit the involvement of a nurse in the assisted dying of the patients

PLACE OF THE ETHICS COMMITTEE: missions

 Educate the hospital and its employees as well as the other constituents of the hospital
 Develop policies with regard to the problem areas, especially problems of death and dying
 Act as advisory consultants to healthcare providers and families

PLACE OF THE FAMILY IN DEATH AND DYING

 Surrogates are consulted since their feelings, rights and obligations are involved
 They may know the factors that would call for prolongation of even a vegetative life
 Questions of inheritance and need for farewell of other family members
COGNITIVE DEVELOPMENT
Jean Piaget
STAGE OF DEVELOPMENT AGE SPAN NURSING IMPLICATIONS
Sensorimotor
 Neonatal reflex  1 month  Stimuli are assimilated into beginning mental images. Behavior is
entirely reflexive.

 Primary circular reaction  1–4 months  Hand–mouth and ear–eye coordination develop. Enjoyable activity
for this period: a rattle or tape of parent’s voice.

 Secondary circular reaction  4-8 months  Infant learns to initiate, recognize, and repeat pleasurable
experiences from environment. Good toy for this period: mirror;
good game: peek-a-boo

 Coordination of secondary  8-12 months  Infant can plan activities to attain specific goals. Good toy for this
reactions period: nesting toys (i.e., colored boxes)

 12-18  Child is able to experiment to discover new properties of objects

 Tertiary circular reaction months and events. Good game for this period: throw and retrieve

 Invention of new means through  18-24  Transitional phase to the preoperational thought period. Good toys
mental combinations months for this period: those with several uses, such as blocks or colored
plastic rings.
Preoperational thought 2–7 years Thought becomes more symbolic; can arrive at answers mentally
instead of through physical attempt. Comprehends simple abstractions
but thinking is basically concrete and literal. Child is egocentric (unable
to see the viewpoint of another). Displays static thinking (inability to
remember what they started to talk about, so at the end of a sentence,
children are talking about another topic). Concept of time is now, and
concept of distance is only as far as they
can see. Centering or focusing on a single aspect of an object causes
distorted reasoning. No awareness of reversibility (for every action,
there is an opposite action) is present. Unable to state cause–effect
relationships, categories, or abstractions. Good toy for this period:
items that require imagination, such as modeling clay.
Concrete operational thought 7–12 years Concrete operations include systematic reasoning. Uses memory to
learn broad concepts (fruit) and subgroups of concepts (apples,
oranges). Classifications involve sorting objects according to attributes
such as color; seriation, in which objects are ordered according to
increasing or decreasing measures such as weight; and multiplication,
in which objects are simultaneously classified and seriated using
weight. Child is aware of reversibility, an opposite operation or
continuation of reasoning back to a starting point (follows a route
through a maze and then reverses steps). Understands conservation,
sees constancy despite transformation (mass or quantity remains the
same even if it changes shape or position). Good activity for this period:
collecting and classifying natural objects such as native plants or sea
shells. Expose child to other viewpoints by asking questions such as,
“How do you think you’d feel if you were a nurse and had to tell a child
to stay in bed?”
Formal operational thought 12 years Can solve hypothetic problems with scientific reasoning. Good activity
for this period: “talk time” to sort through attitudes and opinions.