Chapter 6 - Lecture

Question 1

What are the elements of informed consent? (Health care consent act of Ontario, 1996)

Answer 1

1. The individual is competent to consent (I.e., capable of consenting)
2. The individual must be
   informed by the practitioner
3. Consent is procedure specific
4. There is a Q&A period
5. Consent is voluntary (Not obtained by misrepresentation or fraud)

Question 2

What is advanced care planning?

Answer 2

A process in which individuals indicate their treatment goals and preferences with respect to care at the end of life. This can result in an advance care plan (i.e., living will).

Question 3

What is an advanced directive?

Answer 3

Statement made by a competent person about what kind of treatment is desired, should they become unable to make such decisions or communicate them at some time in the future.

Question 4

What is a living will?

Answer 4

It is a type of advance directive, it allows an individual to refuse life-sustaining treatment in the event they are terminally ill and the administration of treatment would only prolong the dying process.

Question 5

Advanced care planning in Canada.

Answer 5

95% of Canadians think it is important to have a clear conversation with a loved one about the type of care they want at the end of life.
Only 30% have had such a conversation
Only 16% have done something as a result of the conversation, such as creating a living wlll (Canadian Medical Association, 2014).

Question 6

What are the five steps of advanced care planning?

Answer 6

Advanced care planning is a way to share your wishes for future health care, and to name someone who can speak for you if you couldn’t speak for yourself. There are 5 steps:
1) Think - what are your values, beliefs, and understanding about your care and specific medical procedures?
2) Learn - about different medical procedures and what they can and can’t do
3) Decide - who will be your substitute decision maker? Someone who is willing and able to speak for you if you can’t speak for yourself.
4) Talk - about your wishes with your substitute decision maker, loved ones and your doctor.
5) Record - your wishes, it is good to write them down or make a recording of your wishes.

Question 7

What are concerns about living wills?

Answer 7

1) To be effective, people need to have them

2) People have to decide what treatment they would want if they are incompetent

3) People have to accurately and lucidly state their preference about end of life care.

4) The living will has to be available to people making the decisions for the patient.

5) People must understand and heed the instructions.

Question 8

Advanced directives: Health care proxies.

Answer 8

It is possible to appoint a surrogate ( a “proxy”) to make decisions about medical treatment if you become unable to do so (also known as durable power of attorney for health care).
When a surrogate or proxy makes decisions for an incapacitated or incompetent patient, it is called substituted judgment.
May be relative, friend, attorney, or one who knows your preferences.
A court may revoke the proxy’s power if that person acts contrary to your best interests or known desires.

Question 9

Advanced directives and emergency care

Answer 9

Unless notified otherwise, hospital staff and emergency personnel will start CPR to help patient.
The challenge is to eliminate ambiguity about your intended plan of treatment and clearly communicate it to caregivers.
In the hospital, a do not resuscitate (DNR) order is put in your chart by your physician.
First responders generally do not make decisions about who wants to be saved or who doesn’t. They are legally required to initiate CPR unless there is clear evidence that the person has a valid DNR order provided by the physician. Ensure that your instructions are readily available to emergency personnel
Medic – Alert bracelets or wallet cards are helpful signalling the fact that a should not receive CPR, but still a chance they won’t be honored

Question 10

What is a coma?

Answer 10

Coma: A state of profound unconsciousness and unresponsiveness lasting a few days or weeks. The outcomes vary: People can regain consciousness, progress to a vegetative state, or die.

Question 11

What is a vegetative state?

Answer 11

Vegetative State: Patient may respond to painful stimuli, but there is no detectable awareness. Eyes may be open. Persistent if after 4 weeks.
“Awake but unaware”

Question 12

What is a permanent vegetative state?

Answer 12

Considered permanent if after 3 months (if from cardiac arrest or drowning) or 12 months (if traumatic brain injury).
The brain stem is spared, but there is no cognitive function.
Preserves the ANS, so they can still perform things like sleep cycles
Due to damage in both cerebral hemispheres.
People with PVS can go home, but need home support i.e., ventilation.

Question 13

What is the difference between coma and PVS?

Answer 13

A person in a coma needs hospital care, as there is loss of lower brain pons and function.
High risk of pneumonia, bed sores, infection. (Risk factors for death)
Some brain activity in coma.
Unacceptable rate of false positive of PVS and false negatives

Question 14

What is a minimally conscious state?

Answer 14

Patient exhibits fluctuating or intermittent periods of awareness of self and environment. Patients may smile or cry in response to the content of emotional content or stimuli. Can follow simple commands, (I.e. yes or no), can verbalize with gestures, appropriate crying or smiling, appropriate response to emotional stimuli gesturing and direct response to the linguistic content of questions, directed of reaching objects.
Modification of touch or grasp to accommodate the size and shapes of objects, pursuing eye movements on external visual stimuli’s
Although they display cognitive functioning, they are similar to VS –> so severely impaired that they are immobile, can’t perform any meaningful daily activities of daily living, they may have bowel and bladder incontinence, they may require a feeding tube, but are usually able to breathe without a ventilator.

Question 15

What are the three types of minimally conscious states?

Answer 15

1) developmental or congenital injuries to the brain that occur before or after birth
2) Acquired traumatic or non-traumatic injuries to the brain i.e., severe head injury
3) Progressive degenerative disease of the CNS system ie., severe alzheimers.

Question 16

What are aspects of the Terry Schiavo Case?

Answer 16

1998-2003: Court struggle between Terri Schiavo’s husband and her parents. Eight years after her cardiac arrest and subsequent persistent vegetative state, husband wanted to remove her feeding tube. Parents claimed she was in a minimally conscious state.
“Terri’s Law” passed by the Florida legislature (to reinsert feeding tube), then overturned.

Inspired increase in living wills after her death.
2007
Ranked in people that had moved us most affect on us
She didn’t have an advanced directive
Parents said that it would be murder to remove her feeding tube.
19 Courts heard their arguments –> all voted in Michael’s favour.
“Roe v. Wade decision of Euthanasia.”
Autopsy showed significant brain damage…

Exposed 3 modern myths about life and death:
Death with dignity is attainable as long as people make living wills
Only patients themselves are permitted to take quality of life into account when making life-sustaining decisions
Medical innovations and miracle cures bring promise of extending life indefinitely

Question 17

What is physician assisted death?

Answer 17

Assisted death = assisted suicide: Refers to providing someone with the means to kill themselves.
In certain states where it is legal, the physician hastens a death by providing lethal drugs or advice on suicide with the understanding that the patient (not the physician) administers the fatal dose.

This is seen as less acceptable then withdrawing life support.
it was up to the individual States to craft a policy regarding physician-assisted death, and each State could decide whether to prohibit it or permit it
Is legal in eleven States, California, Colorado, District of Columbia, Hawaii, Montana, Maine, New Jersey, New Mexico, Oregon, Vermont, and Washington

Question 18

What is the Nancy Cruidan case?

Answer 18

Nancy Crucian Case –> 1997 Supreme court was noting that the right to refuse treatment was based on the right to maintain bodily integrity, not on a right to hasten death, when treatment is withheld or withdrawn, it’s to honour the patient’s wishes, not cause death (She had to go to Switzerland to get physician assisted death)

Question 19

Oregon’s death with Dignity act

Answer 19

Death with dignity act: Allows physicians to prescribe legal medication to terminally ill patients, 18+, legal residents, and able to make communicating health care decisions to your health care practitioners, and importantly diagnosed with a terminal illness that will lead to death within six months
Want these prescriptions because: They have a decreasing ability to participate in activitiesthat make life enjoyable, they’re concerned about a loss of dignity, concerned about theloss of autonomy.

Allows physicians to prescribe lethal medication to terminally ill patients.
Available only to legal residents of Oregon.
In 2021, 383 prescriptions were written, and 238 people used them.
Since the law was passed in 1997, a total of 3280 people have had DWDA prescriptions written and 2159 patients have died from ingesting medications prescribed under the DWDA.

Question 20

Landmark Judicial Decisions in Canada regarding physician assisted suicide:

Answer 20

2011: Gloria Taylor, who had ALS, challenged the law against physician-assisted suicide.
2012: The BC court ruled the Criminal Code of Canada provisions against assisted dying violated the rights of the gravely ill.
June, 2014: Bill 52 – A Quebec Act respecting end-of-life care. The bill legalized “medical aid in dying.”
June, 2016: The Supreme Court of Canada passed Bill C-14. Canadians with terminal illnesses could legally choose to die with a physician’s or nurse practitioner’s assistance.
March, 2021: Bill C-7 passed. The eligibility criteria for Medical-Aid-In-Dying (MAiD) were expanded.
But there were many problems with Bill c. Fourteen. Your death had to be what they call reasonably foreseeable.
If your death was not considered imminent. For example, having Parkinson’s disease, dementia, or even advanced cancer, you were excluded from the law
You also had to be competent to make the request right at the time of death, which was impossible for so many people, because they were very, very ill, or they actually did have dementia at thetime of death, even though they had requested it before

Question 21

Bill C-7

Answer 21

Who is eligible in Canada?
Under Bill C-7, two independent health care professionals need to evaluate an individual to determine whether they qualify for MAiD. To qualify, an individual must be 18 years or older, be eligible for government funded health insurance, made a voluntary request, and have a “grievous and irremediable medical condition”:
Have a serious illness, disease or disability (excluding a mental illness until March 17, 2023)
Be in an advanced state of decline that cannot be reversed
Experience unbearable physical or mental suffering from an illness, disease, disability or state of decline that cannot be relieved under conditions that the person considers acceptable.
Individuals must also be capable of providing informed consent at the time that MAiD is provided.
You have to be eligible for government-funded health insurance in Canada. This prevents visitors or tourists from accessing made in Canada. You have to be eligible for government-funded health insurance in Canada. This prevents visitors or tourists from accessing made in Canada.
You have to have made a voluntary request for made That was not the result of somebody pressuring you into it.
You have to give informed consent to receive, made after having received all the information needed to make that decision, including a medical diagnosis, what other forms of what other available forms of treatment there might be and any options you might have to relieve your suffering, including palette of care.

Question 22

What are the two types of maid that are allowed in Canada?

Answer 22

It’s also important to note that in Canada two types of made are allowed. So number one a physician or nurse practitioner can directly administer a substance that causes the death of the person who has requested it. or a nurse, a physician, or nurse practitioner can give or prescribe a patient, a substance that they can then self administer to cause their own death.

Question 23

Bill C-7: Consent

Answer 23

The law requires that consent is provided at two time points:
1) at the time of the written request,
2) immediately before MAiD is conducted (“final consent”).
Only for people whose “natural death is reasonably forseeable”, there is an option for a waiver of final consent. This is in case the individual may lose the capacity to consent at the time of MAiD, so they sign a waiver.
For people whose death is not reasonably forseeable (So that would be someone that maybe had cancer that is, spread all over their body, and that is considered reasonably foreseeable.
),there is a 90 day wait period before MAiD. The requirement is meant to explore “other treatments and services that could relieve the person’s suffering”
So when there’s a waiver of final consent. It allows someone who has already been assessed, and a proof are made to receive it on their chosen date. Even if they Don’t have the capacity to consent at the time of the procedure. (This would be based on a signed and dated agreement with their medical practitioner).

Question 24

Audrey Parker’s experience with MAID

Answer 24

Forced to access MAID earlier than she would’ve liked: because she was afraid that shewould lose capacity and not be able to provide consent at the time of the made procedure, which is what the law at that point required. (and that request has to be made in writing and done in front of an independent witness, who isn’t one of the two health care professionals that do the evaluation)

Question 25

Bill C-7 Controversies and Debate

Answer 25

A growing number of disability activists oppose the changes in Bill C-7 as well as the ones that are coming in March 2023. Some of the important points are:
The government does not provide enough resources for those living in poverty, and it is easier to obtain MAiD than to obtain financial and other support to make ends meet
Failure to care for the most vulnerable in society vs. improvement the lives of people living with disabilities
People forced into euthanasia by their circumstances; concern healthcare providers will encourage euthanasia
There are increasing reports of people who are applying for made simply because they cannot afford to keep on living

A number of media reports show that Canada has some of the lowest social care spending of any industrialized country; Palliative care is only accessible to a minority of people and the waiting times in our public health care sector can be unbearable
It’s expensive for the um province or for the country, but assisted suicide, or made only cost taxpayers a little over two thousand dollars per person
lawyers and other experts in and like policy, say that there are extensive guardrails in the system to protectCanadians, that you have to meet rigorous eligibility, criteria, and being poor or not having a home or a home that suitable for you does not make you eligible for made

Question 26

The Rule of Double Effect

Answer 26

States that a harmful effect of treatment, even if it results in death, is permissible if the harm is not intended and occurs as a side effect of a beneficial action.
Medication to relieve pain may be given even though a sufficient dose may hasten the patient’s death.
Sometimes called “terminal sedation.” It’s the double effect because it is treating pain (good effect) and hastening death (bad effect).

This is a separate topic from physician assisted suicide, but it’s related and that involves a treatment for an ill patient that might have the unintended effects of causing death please note that the double effect is not considered made because, even if it hastens death, the intent is to relieve pain

Question 27

Italian Study: Palliative sedation

Answer 27

Relieving pain in dying patients should be a primary concern of healthcare, but doctors sometimes are resistant to offering pain relief because they are worried about hastening death.
Italian study randomized patients to receive palliative sedation therapy vs. no sedation (Maltoni et al., 2009). All patients were at end of life.
However, the two groups did not differ on survival (12 vs 9 days; but the finding was not statistically significantly different)

Question 28

Public Acceptance of Hastening Death

Answer 28

Withdraw artificial life support from a patient who cannot live without such intervention (Most acceptable)
Withdraw artificial feeding or hydration from a patient who does not require any other artificial life support
Provide pain relief, knowing it may hasten death
Provide a terminally ill patient with the means to kill themselves
Administer a lethal injection to a severely or terminally ill patient (least acceptable)

Question 29

Euthanasia

Answer 29

From the Greek, “easy death”
Illegal in the United States
The intentional act of killing someone who would otherwise suffer from an incurable and painful disease
Fatal injection

Question 30

Non-voluntary euthanasia vs in-voluntary euthanasia

Answer 30

• Non-voluntary euthanasia is defined is when you do euthanasia to somebody and the consent isunavailable. (Illegal in all countries)
• Involuntary euthanasia is defined as when euthanasia is done without asking consent or against thepatient’s will, it is also illegal in all countries and is usually considered murder

Question 31

What are the three elements of euthanasia in Canada? What is different in the united states?

Answer 31

In the Canadian Medical Association’s definition, euthanasia includes the following three elements:
The patient has an incurable illness,
The agent knows about the person’s condition and commits the act with the primary intention of ending the life of that person,
The act is undertaken with empathy and compassion and without personal gain.

In the United States, the differentiation is a lot clear because made in the US involves a prescription that a medical provide writes for a lethal dose of a drug and the patient has to take it themselves and euthanasia it’s a legal film production that someone is giving you

Question 32

Psychiatric Euthanasia

Answer 32

Four important psychiatric euthanasia criteria from the Netherlands are: (from Macleod, 2012)
The patient’s request must be voluntary, enduring and well considered
The patient’s suffering must be lasting and unbearable
The patient must be well-informed about the current situation and prospects
All other options for care must have been exhausted or refused by the patient
For psychiatric euthanasia in these nations patients have to demonstrate to three doctors physicians who are independent of each other, a reasonable a reasonable understanding and convict convincingjustification their request

Question 33

Arguments against psychiatric euthanasia

Answer 33

Arguments against: patient may ask for assisted dying and receive euthanasia when there were competence psychiatric psychotherapy or other clinical care options that might have permitted the person to improve their quality of life, to such an extent that they wouldn’t have wanted to end it prematurely.
there’s also several studies documenting that people often regret trying to kill themselves when they’re suicidal and are grateful that they didn’t succeed
Other psychiatry’s have written commentaries that say that the wish to die is not stable if mental health problems are evident
the majority of people in the Benelux nations who received psychiatric euthanasia typically have had treatment resistant depression
Arguments against this are that primary care physicians have limited ability to detect psychiatric disorders