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Death and Dying
The Dying Process:
Modern medicine has enabled people to live
longer and survive illnesses that once caused
death. This has created some ethical and
moral dilemmas for the healthcare
profession. Patients can now be kept alive by
medical technology, but death is inevitable
for everyone. Expired means “died.”
The Legal Definition of Death:
The actual determination of death is critical
because of the advances in medicine such as
organ transplantation and life support, so there
is a Criteria or standards for death, which assist
in the determination that death has occurred:
Loss of heartbeat, significant drop in body
temperature, loss of body color and rigor mortis
Symptoms may not appear until several hours
after death or not at all if life-support equipment
is used. The best example of this is,
The Karen Ann Quinlan Case
Who fell into an unconscious vegetative state
from prescription drugs and an alcohol overdose
A tracheotomy to help with breathing and a
nasogastric tube for nourishment kept her alive
Parents appealed to have respirator discontinued
and after many reversals in court,
The respirator was discontinued, but feeding
tube continued
Karen lived in coma for ten years without
Two definitions of death:
Cardiac and Brain-oriented death
Cardiac Death
Death in which heart has stopped
Lack of pulse or breathing
Irreversible loss of all cardiac function
Serious problem for organ transplants
Many people believe that a cardiac oriented
definition of death is inadequate.
Death is considered legal.
Brain-Oriented Death
Death occurs when there is irreversible
cessation of all brain function
Most states accept this definition of death
Heart and lung functions can be maintained
by mechanical means after brain function has
stopped, so time of death depends on
cessation of brain activity.
Harvard Medical: Criteria for Definition of
Irreversible Coma, i.e. Brain Death
Unreceptive and unresponsive with total
unawareness of externally applied and painful
No spontaneous movements or breathing,
absence of response to pain, touch, sound, or
No reflexes, with fixed dilated pupils, lack of
eye movement, and lack of deep tendon
Because of controversy over the criteria for
determining brain death, in 1990 Congress
enacted, The Uniform Determination of Death
Act: which states the following:
An Individual is dead if he or she has
sustained either:
Irreversible cessation of circulatory and
respiratory functions, or
Irreversible cessation of all functions of the
entire brain, including the brain stem
Types of Patient Treatment in Final Stages
Withdrawing vs. Withholding Treatment
Withdrawing means to discontinue treatment
after it has been started
Withholding means never starting treatment
Many believe both are ethically wrong.
Patients have the legal right to refuse
treatment and food
Active Euthanasia Versus Passive Euthanasia
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. Oregon requires
Passive euthanasia: allowing patient to die
naturally, which is legal, discontinuing
chemotherapy which is ineffective and
burdensome, or painful intravenous tubes. See
Nancy Cruzan
Arguments for Euthanasia
Patient self-determination
Harvesting viable organs
Relief for family if patient has irreversible
Provides means to end patients suffering.
Some arguments in opposition
No certainty regarding death
Research and technology may find a cure for
a terminal disease.
Can relieve financial burden from m families
and patient
Euthanasia can be used indiscriminately
You Be The Judge!
Remember, While you are reading the scenario, try not to
make comments as I want everyone to be able to fully read the
case, OK? Let’s get started
During State performed executions it is common practice for
physicians to be present in order to certify that the prisoner is
dead. He is also there to certify the date day and time of
In states where lethal injection is used as a form of execution,,
the physician administers the lethal drugs.
A state medical association has objected to
The participation of physicians in any and all
They feel that physicians take an oath to “do
no harm.”
Physician should no inject lethal doses of
drugs in order to promote death….. They
(physicians should not act as accessories in
taking of life during execution.
The association contends that the physician is
nothing more than an accessory to murder.
What are your thoughts on execution?
Should physicians take part in executions…
Why? Why Not? Answer with comments.
Is the physicians role in executions ethical?
Why/Why Not?
Direct Vs. Indirect Killing
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
Ordinary Vs. Extraordinary Treatment
Ordinary: treatment or procedure that is
morally required, such as fluids and comfort
measures, may be called appropriate
Extraordinary measures: procedures and
treatment that are morally expendable, such
as chemotherapy, tube feedings, CPR, and
mechanical breathing or respirators may be
called inappropriate
Additional examples of treatment that might
be ordered for the terminally ill:
CPR: Cardiopulmonary Resuscitation
Respirator, Tube Feeding
Kidney Dialysis
What would you do?
Right to Die or Right to Refuse Treatment
Patients have the right to refuse treatment
If refusal places their lives in danger,
physicians sometimes take legal action
through the courts.
Five Stages of Dying
According to Dr. Elizabeth Kubler-Ross,
author of Death and Dying, the dying
process is divided into five stages, which the
patient, family members and caregivers all
The stages may overlap and may not be
experienced by everyone involved in stated
order, but all are present in a dying patient.
These stages are important to all concerned,
they are
• Denial: Refusal to believe that dying is taking place.
• Anger: Patient may be angry with everyone and
express that anger often to those around him/her.
• Bargaining: Gaining time by making promises to God
in return for a cure.
• Depression: There is a deep sadness over loss of
independence, health and eventually life.
• Acceptance : This stage carries a sense of peace and
All stages of the dying process have impact
Quality-of-Life Issues.
The medical profession uses: general health,
physical functioning, role limitations, bodily
pain, social function, vitality and mental
health to assist and assess the patient
quality of life and comfort.
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 a drug or
Many physicians now believe a patient’s pain
and suffering should be controlled with use
of Medication and other measures
Types of care for End Stage:
Hospice Care: Originated in France.
Committed to keeping patients as pain-free
as possible. They are focused on providing
comfort measures, emotional support, and as
pain-free as possible environment for the
patient at end of life. The staff is specially
trained to provide the proper and necessary
care for a patient in the final stages.
Palliative Care: Total care of patients whose
disease is no longer responsive to curative
therapy. Palliative care consists of comfort
measures meant to provide a relief of pain
and suffering so patient can die with dignity.
Emphasizes symptom control, which is
opposite of curative care
In Palliative and Hospice care, emphasis is on
the patient and their end of life, death with
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
Many insurance companies will deny payment
on a insurance policy if the cause of death is
ruled a suicide.
Advance Directives
Documents such as living will, durable power of
attorney for health care, Uniform Anatomical Gift Act,
and do not resuscitate (DNR) orders, must be in place
while the patient is competent to make decisions.
Appointing one individual to be a Durable Power of
Attorney is vital to having the patient desires and
needs followed. Providing a copy to the patient’s
medical team is also vital.
Advance Directives Limit type and amount of medical
care and treatment patients will /wish to receive if
they become incompetent and have poor prognosis.
They provide choices in life and death for the patient.
Be sure patient and physician are in agreement over
advanced directives.
Death Certificates
Must be signed with time, place, date and cause
of death by an administering physician. They
Must also include the following: Name and
address of decedent, Age, Place and date of
birth, Names parents (including mother’s
maiden name),Birthplace of parents, Race,
Decedent’s occupation.
Two types: Certified and Non certified. Always
get copies of both. Death certificates, must be
provided to certain agencies, i.e. Social Security,
Pension Funds, Insurance companies, and some
require certified copies other agencies do not.
Medical Examiner Cases:
Legal investigation by medical examiner or coroner in case
of suspicious death. Investigation is required if death is:
Violent in nature (homicide, suicide, accident)
Caused by criminal abortion
Related to contagious or virulent disease
A person confined to jail or correctional institution
Result of unexplained or unexpected cause
Caused by electrical, radiation, or chemical injury
A person who had no physician in attendance within 36
hours of death
A person whose body is not claimed by friend or relative
A child under age of two if death is from unknown cause
A person of unknown identity
Glenn Ross is 55. He is diagnosed with inoperable pancreatic
cancer. Prognosis is poor. Drs. Say he will live about six
months. Chemotherapy provided no relief or benefit. After
three months with his condition worsening, he stops
treatment. Thereafter he was admitted to a nursing facility
for terminal care. Glenn’s son, who lived in another state
visited his father at the nursing home and demanded that his
father be hospitalized and placed on chemotherapy
immediately. When the physician explained that
chemotherapy would not provide any recovery, his son
threatened to sue.
Does the son have a legitimate reason to sue?
What are the ethical issues?
What a possible solutions to this case?
You will need to think about some legal, moral
and ethical issues in the health care system to
discuss in your paper . Research some of the
issues we discussed throughout the term and
check other sources….
Please be sure to answer questions in full and
complete statements. Watch your spelling
grammar and punctuation.
Be sure to reference. Remember there are many
sites available on lone for guiding you through
proper citations. If you provide the writing
center 48 hours, they can review your work.
Do not wait until the last minute to complete
your work. What can go wrong will go wrong,
if you know what I mean. I want you to be
You know where to find me if you need
questions answered.