Law & Legislation Week6

End of Life Issues

Chapter 16

LEARNING OBJECTIVES

Discuss the human struggle to survive and the right to autonomous decision-making.

Describe how patient autonomy has been impacted by case law and legislative enactments.

Discuss the following concepts: preservation of life with limits, euthanasia, advance directives, futility of treatment, withholding and withdrawal of treatment, and do-not-resuscitate orders.

LEARNING OBJECTIVES – II

Discuss the purpose of an ethics committee and its consultative role in the delivery of patient care.

Explain end-of-life issues as they relate to autopsy, organ donations, research experimentation, and clinical trials.

Describe how human genetics and stem cell research can have an impact on end-of-life issues.

Dreams of Immortality

Human struggle to survive

Desire to prevent & cure illness

Advances in medicine & power to prolong life

Process of dying can be prolonged

Ethical & legal issues have increased

involving entire life span, from right to be born to right to die

Scope of Ethical Issues

Entire Life Span

The Right to be Born

The Right to Die, &

Everything in between, e.g.,

to choose treatment

to refuse treatment for oneself

to refuse treatment for another

to limit the suffering one would endure

Ethical Dilemmas Arise

When values,

rights,

duties

& loyalties conflict.

Autonomy

Right of a person to make one’s own decisions.

Patient has right to accept or refuse care even if it is beneficial to saving his or her life.

Autonomy may be inapplicable in certain cases

affected by one’s disabilities, mental status, maturity, or capacity to make decisions.

Quinlan court Relying on: Roe v. Wade

Announced the constitutional right to privacy protects a patient’s right to self-determination.

State’s interest did not justify interference with her right to refuse treatment.

Quinlan’s father was appointed her legal guardian

Cruzan Case

Supreme Court held that right-to-die should be decided pursuant to state law, subject to a due-process liberty interest, and in keeping with state constitutional law.

Cruzans returned to Missouri probate court:

Judge Charles Teel authorized physicians to remove the feeding tubes from Nancy.

testimony presented demonstrated clear & convincing evidence Nancy would not have wanted to live in a persistent vegetative state.

Legislative Response: Patient Self-Determination Act of 1990

Requires healthcare organizations to explain to patients their legal right to direct their own care

Right to refuse medical treatment

Right to formulate advance directives

Right to appoint surrogate decision-maker

Federal reimbursement requires compliance with Act

Preservation of Life

Medical ethics does not require patient’s life be preserved at all cost under all circumstances.

Ethical integrity

of a profession is not compromised by a patient’s decision to forego medical care.

Right to body integrity.

Euthanasia

Mercy killing of hopelessly ill, injured or incapacitated

Active

intentional commission of an act, such as giving patient lethal drug

Passive

occurs when life-saving treatment (such as a respirator) is withdrawn or withheld

Physician-Assisted Suicide

Oregon’s Death with Dignity Act of 1994

physician-assisted suicide became a legal medical option for the terminally ill residents

U.S. Supreme Court, in two unanimous & separate decisions, ruled

laws in Washington & New York prohibiting assisted suicide are constitutional

yet U.S. Supreme Court also ruled that states can allow doctors to assist in suicide of their terminally ill patients.

Advance Directives – I

Making Preferences Known

Obligation to make medical preferences known to treating physician.

Any glimmer of uncertainty as to a patient’s desires in an emergency situation should be resolved in favor of preserving life.

Advance Directives – II

Living Will

Health Care Proxy

Determining Incapacity

Agent’s Rights

Durable Power of Attorney

Guardianship

Substituted Judgment

Futility of Treatment

Physician recognizes effect of treatment will be of no benefit to the patient.

Morally, a physician has a duty to inform patient when there is little likelihood of success.

Determination as to futility of medical care is a scientific decision.

Withholding & Withdrawing Treatment – I

Withholding of treatment

decision not to initiate treatment or medical intervention for the patient.

Withdrawal of treatment

decision to discontinue treatment or medical interventions for the patient.

Withholding & Withdrawing Treatment – II

When

Patient in a terminal condition & there is reasonable expectation of imminent death.

Patient a non-cognitive state with no reasonable possibility of regaining cognitive function.

Restoration of cardiac function will last but for a brief period.

DNR Orders

DNR orders written by a physician, indicate that in event of cardiac or respiratory arrest, no resuscitative measures should be used to revive patient.

Ethics Committee

Committee offering objective counsel when facing difficult health care issues & decisions resource to patients, families, & staff.

Includes wide range of community leaders.

Analyzes ethical dilemmas, advise & educate health care providers, patients, & families.

Assists patients & family in coming to consensus with options that best meet patient’s care needs.

Ethics Committee Function

Policy & procedure development

Educational role

Consultative role

Political Advocacy

Autopsy

Postmortem examinations to determine cause of death.

Add to medical knowledge.

Necessary for criminal activity or suspicious deaths.

Deaths during surgery are reportable.

Consent required.

Organ Donations – I

Federal regulations

hospitals to have, & implement, written protocols regarding organ procurement.

notification duties concerning informing families of potential donors.

Discretion & sensitivity in dealing with families.

Organ Donations – II

Education

facilitate timely donation & transplantation

Uniform Anatomical Gift Act

allows a person to make a decision to donate organs at the time of death and allows potential donors.

Organ Donations – III

Millions of people suffer from kidney disease, but in 2007 there were just 64,606 kidney-transplant operations in the entire world. In the U.S. alone, 83,000 people wait on the official kidney-transplant list. But just 16,500 people received a kidney transplant in 2008, while almost 5,000 died waiting for one.

—Alex Tabarrok, The Wall Street Journal, January 8, 2010

Research, Experimentation & Clinical Trials

Combination of federal & state regulations

Office of Research Integrity

Institutional Review Board

Informed Consent

Duty to Warn

Risks, benefits, alternatives

Food & Drug Administration

Organ Human Genetics – I

Study of inheritance as it occurs in human beings, includes stem cell research, clinical genetics (e.g., genetic disease markers) & molecular genetics.

Genetic markers are genes or DNA sequences with a known location on a chromosome that can be used to

identify specific cells & diseases

individuals & species

Organ Human Genetics – II

Genetic Information Nondiscrimination Act of 2008 prohibits

discrimination on the basis of genetic information with respect to the availability of health insurance & employment

employers from using an individual’s genetic information when making hiring, firing, job placement, or promotion decisions

STEM CELL RESEARCH

Use of embryonic stem cells to create organs and various body tissues.

highly controversial, involving religious beliefs and fears as to how far scientists might go in their attempt to create, e.g., another human being.

When We Finally Know

… When we finally know we are dying,

All sentient beings are dying with us,

We start to have a burning, almost heart-breaking sense of the fragility and preciousness of each moment and each being, and from this can grow a deep, clear, limitless compassion for all beings.

−Sogyal Rinpoche

REVIEW QUESTIONS – I

Discuss how one caregiver’s beliefs can be in conflict with another when making end-of-life decisions. Consider topics discussed on morality, virtues, situational ethics, autonomy, and medical paternalism when framing your answer.

Discuss the ever-expanding role of ethics committees, including internal operational issues & external influences that affect internal operations.

What are the differences between allowing a patient to die and physician-assisted suicide?

REVIEW QUESTIONS – II

Examine the statement: “The inherent risk is that society’s faith in doctors as healers would become subverted if doctors participate in physician-assisted suicide.“

Constitutionally, what gives patients the right to self-determination?

Explain why you think the Schiavo case is an example of legislating morality.

Law & Legislation Week6

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