Critically Ill Flashcards
Why is withholding or withdrawing life-support systems one of the biggest ethical problems of our time?
1- available technology: can prolong life but not necessarily improve quality
2- long standing medical tradition: do everything possible
3- often final efforts inconsistent with pt. wishes: most Americans die alone, in pain and on some type of life support
what is an advanced directive?
statement (usually written) that gives directions for your medical care should you become unable to speed for yourself.
allows people to indicate the manner in which they want to die
what are the 4 types of advanced directives?
1- DNR (do not resuscitate) or No code order
2- living wills
3- durable power of attorney for health care (AKA health care proxy)
4- oral advance directive
what is a DNR?
“do not resuscitate” or “no code order”
a physician’s order in the pt. record indicating desire not to be revived if heart or breathing stops
what are living wills?
directions to physicians on how to treat you (withhold or withdraw life sustaining tx) if you develop a terminal condition or a “persistent vegetative state”
what is a durable power of attorney for health care?
“health care proxy”
designation of a surrogate decision maker
what is an oral advance directive?
tell physician and family what you should want in given situations (should be documented in medical record)
how do you obtain an advanced directive?
DNR: physician can post the order (per direction of pt. or guardian)
Living wills and health care proxy: department of health (don’t need an attorney)
Hospitilization: asked if you have one, if not they can help you complete one
Federal Patient Self-Determination Act (1991)
what is the caring response when working with dying patients?
1- confident bedside manner 2- self-awareness of own feelings 3- listen actively 4- ask, don't assume 5- let patients set tone of conversations 6- touch matters 7- be honest and hopeful; realistic and positive 8- do not isolate
what is “medically futile care”?
working with dying patients
life-prolonging interventions when no chance to achieve beneficial outcome, only prolong life
nutrition and hydration are especially challenging
what is euthanasia?
the INTENTIONAL killing by act or omission of a dependent human being for his/her alleged benefit
the key word here is “intentional”. if death is not intended, it is not an act of euthanasia
what is voluntary euthanasia?
when the person who is killed has REQUESTED to be killed
what is non-voluntary euthanasia?
when the person who is killed made NO REQUEST and gave NO CONSENT
AKA homicide
what is involuntary euthanasia ?
when the person who is killed made an expressed wish to the contrary
what is assisted suicide?
someone provides an individual with the info, guidance and means to take his/her own life with the intention that they will be used for this purpose
what is physician assisted suicide?
when it is a doctor who helps another person to kill themselves
or clinically assisted suicide (not just a doctor)
what is euthanasia by action?
intentionally causing a person’s death by performing an action such as by giving a lethal injection
what is euthanasia by omission?
intentionally causing death by not providing necessary and ordinary (usual and customary) care or food and water
Purtillo’s “assisted suicide” =
physician provides means
physician necessary but not sufficient
pt. has active role
Purtillo’s “medically administered euthanasia”=
physician commits act by medical means
physician necessary and sufficient
pt’s illness provides context for act
what is palliative care?
supportive care to prevent and relieve pain and other symptoms during the dying process
more awareness and humility about what medicine can and can’t do
helps patients (and loved ones) deal with their own death more realistically- as part of life
what is hospice?
set up to provide palliative care and abatement of pain, either at home or in an environment that encourages dignity, but does nor cure or treat intensively
what is the legal status for physician-assisted suicide?
4 states are legalized
via legislation: OR, VT, WA
via court ruling: Montana
46 states consider it illegal:
39- laws prohibiting
3- prohibit via common law
4- law unclear
no Federal laws on assisted suicide, except via homicide laws
what are some end of life concerns?
loss of autonomy
not participating in activities that made life enjoyable
loss of dignity
what is assisted suicide like in Europe?
legal for adults in Belgium, Netherlands and Luxembourg
Netherlands allows euthanasia for children older than 12, under some circumstances
Belgium: removes all age restrictions, stating that any incurably sick child may request to end their suffering if “conscious” and if equipped with what is calls a “capacity of discernment”
what are the 6 major legal cases?
Karen Quinlan Joesph Sailewicz Claire Conroy Mary O'Connor Nancy Cruzen Terri Schiavo
describe the case of Karen Quinlan:
1976 NJ
on a ventilator: no advance directive
“substituted judgement”
father’s discussion was “substituted” for hers
ventilator removed 1976; died from pneumonia 1985
fundamental criterion: medical prognosis
describe the case of Joseph Salewicz:
1976 MA
profoundly mentally retarded
guardian= institution
withholding life-saving tx?
“no code-orders”
describe the case of Claire Conroy:
1985 NJ
severe dementia (not persistent vegetative state)
nephew wanted feeding tube removed
over-ruled “substituted judgement”
objective standard: “burdens.. clearly and markedly outweighs its benefits”
describe the case of Mary O’Conner:
1988 NY
similar to Conroy
Ruling: “nothing less than unequivocal proof of a pt’s wishes will suffice when the decision to terminate life support is at issue”
describe the case of Nancy Cruzen:
1990 MO
first case before US supreme court
Missouri Supreme court required “clear and convincing evidence”
decision making: parents, Persistent vegetative state
ventilator was removed; no indication from Cruzen herself
US Supreme Court upheld states’ rights to set their own standards
Inconsistencies among states OK
describe the case of Terri Schaivo:
2005 FL
36 y/o female, cardiac arrest (1990) persistent vegetative state
husband named guardian; petitions court to remove feeding tube
parents intervene, allege abuse
FL house passes “Terri’s Law” and US senate passes “private bill”
US Supreme Court declines to hear case
dies March 31, 2005
