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Death and Dying
Chapter 13
Medical Law and Bioethics, 2nd Edition
Bonnie F. Fremgen
2006 Pearson Education, Inc
Pearson Prentice Hall
Upper Saddle NJ, 07458
The Dying Process
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Death is inevitable for everyone
Modern medicine has enabled people to live
longer and survive disease
Patients can now be kept alive by medical
technology
Health care professionals have a duty to
preserve life
Legal Definition of Death
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Determination of death is important for many
reasons
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Actual determination of death is critical due
to organ transplantation and life-support
systems
Karen Ann Quinlan Case
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April 15,1975: 21-year-old unconscious from a
prescription drug and alcohol overdose
Tracheotomy to help with breathing and nasogastric
tube for nourishment
Father appealed to have respirator discontinued
Respirator discontinued, but feeding tube continued
Lived in coma for ten years without respirator, then
died
Criteria for Death
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Assist in determination that death has
occurred
Loss of heartbeat, significant drop in body
temperature, loss of body color, rigor mortis
(stiffness)
Symptoms may not appear until several
hours after death or not at all if life-support
equipment used
Cardiac Death
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Death in which heart has stopped functioning
Lack of pulse or breathing
Considered a legal death
Irreversible loss of all cardiac function
Serious problem for organ transplants
Brain-Oriented Death
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Death occurs when there is irreversible
cessation of all brain function
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Most states accept this definition of death
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Heart and lung functions can be maintained
by mechanical means after brain function
has stopped
Harvard Criteria for Definition of
Irreversible Coma
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Unreceptive and unresponsive with total
unawareness of externally applied and
painful stimuli
No spontaneous movements or breathing,
absence of response to pain, touch, sound,
or light
No reflexes, with fixed dilated pupils, lack of
eye movement, and lack of deep tendon
reflexes
Uniform Determination of Death Act
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1990 approved
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Individual is dead if he or she has sustained
either
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Irreversible cessation of circulatory and
respiratory functions, or
Irreversible cessation of all functions of the entire
brain, including the brain stem
Withdrawing Versus
Withholding Treatment
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Withdrawing means to discontinue treatment
after it has been started
Withholding means never starting treatment
Many people believe both are ethically wrong
Patients have the legal right to refuse
treatment and food
Active Euthanasia Versus
Passive Euthanasia
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Active euthanasia: intentional killing of the
terminally ill is illegal in all jurisdictions in the
United States except Oregon
Patient-assisted suicide (PAS): physician
provides patient with medical know-how or
means to enable patient to end own life
Passive euthanasia: allowing patient to die
naturally is legal
The Nancy Cruzan Case
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January 11, 1983: 25-year-old injured in auto
accident was left in vegetative state
Feeding tube implanted
Family requested feeding tube be removed
U.S. Supreme Court ruled against Cruzans
New evidence of Nancy Cruzan not wishing to be
maintained as in the Karen Quinlan case
Feeding tube removed and Nancy Cruzan
pronounced dead on December 26, 1990
Direct Versus Indirect Killing
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Direct killing: death is result of another
person’s intended action or inaction
Indirect killing: death is result of
unintentional result of another’s action
Double-effect doctrine: an action may have
two consequences, one desired (and
intended) and one undesired (and
unintended)
Ordinary Versus
Extraordinary Means
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Ordinary: treatment or procedure that is
morally required, such as fluids and comfort
measures, may be called appropriate
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Extraordinary measures: procedures and
treatment that are morally expendable, such
as chemotherapy, tube feedings, CPR, and
mechanical breathing or respirators may be
called inappropriate
Right to Die Legislation or
Right to Refuse Treatment
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Patients have the right to refuse treatment
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If refusal places their lives in danger, legal
action sometimes results
Stages of Dying
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According to Dr. Elizabeth Kubler-Ross, dying
process is divided into five stages patient, family
members, and caregivers all experience
Stages may overlap and may not be experienced by
everyone in stated order, but all are present in dying
patient
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Denial
Anger
Bargaining
Depression
Acceptance
Quality-of-Life Issues
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Measures to assess quality of life include
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General health
Physical functioning
Role limitations
Bodily pain
Social function
Vitality
Mental health
Use of Medications
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Dying patients often spend most of their last
days in moderate or severe pain
Physicians are often reluctant to
overprescribe pain medications for fear
patient may become addicted to drug
Many physicians now believe patient’s pain
and suffering should be controlled with use of
adequate medications
Hospice Care
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Originated in France
Committed to keeping patients as pain-free
as possible
Focused on providing comfort measures,
emotional support, and as pain-free as
possible final environment for the patient
Staff specially trained in caring for dying
patient
An elderly hospice patient
Figure 13-1
Palliative Care
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Total care of patients whose disease is no
longer responsive to curative therapy
Consists of comfort measures
Meant to provide a relief of pain and suffering
so patient can die with dignity
Emphasizes symptom control
Opposite of curative care
Viatical Settlements
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Allow people with terminal illness to obtain money
from life insurance policies by selling them
In exchange for 20 to 50 percent discount on face
value of patient’s insurance policy, patient can have
immediate access to money
Patient names settlement company as recipient of
death benefit
Many use money to provide for medical and nursing
care during final illness
Advance Directives
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Documents such as living will, durable power
of attorney for health care, Uniform
Anatomical Gift Act, and do not resuscitate
(DNR) orders
Popularly known as living wills
Limit type and amount of medical care and
treatment patients will receive if they become
incompetent and have poor prognosis
Choices in Life and Death
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Suicide is considered morally wrong and
illegal in most states
No state punishes people who attempt
suicide, but they may be placed in psychiatric
care if present danger to themselves
Many religions condemn suicide and
euthanasia
The Case of Conjoined Twins
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50 hour operation to separate 29-year-old
twins joined at head
Death resulted during procedure in July 2003
Twins knew of risks but knowingly accepted
risks
Many ethical debates about the separation
Mechanical Heart Recipient
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Implanted in 59-year-old man in July 2001
Did well until he suffered severe strokes from
blood clots
Final days of life spent partly paralyzed and
breathing through a ventilator
Lived for five months with mechanical heart
Death Certificate
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Must include the following:
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Name and address of decedent
Age
Place and date of birth
Names of parents (including mother’s maiden
name)
Birthplace of parents
Race
Decedent’s occupation
Medical Examiner Cases
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Legal investigation by medical examiner or coroner in case of
suspicious death. Investigation is required if death is:
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Violent in nature (homicide, suicide, accident)
Caused by criminal abortion
Related to contagious or virulent disease
Of a person confined to jail or correctional institution
Result of unexplained or unexpected cause
Caused by electrical, radiation, or chemical injury
Of a person who had no physician in attendance within 36 hours of
death
Of a person whose body is not claimed by friend or relative
Of a child under age of two if death is from unknown cause
Of a person of unknown identity