Critically Ill & Dying Patients Flashcards by Chris Gothberg

What are the 3 confounding issues for critically ill & dying patients?

Informed consent
Patient’s rights
Attitudes towards death & dying

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Why is withholding and withdrawing life-support systems one of the biggest ethical problems of our time?

Available technology (can prolong, but not necessarily improve quality)
Long-standing medical tradition (do everything possible)
Often final efforts are inconsistent with Pt wishes (most Americans die alone, in pain and on some type of life support

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What act originating in California lead to the development of advanced directives?

Natural death act 1977

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What is an Advanced Directive? What is its purpose?

Statement (usually written) that gives directions for medical care should you become unable to speak for yourself.
Allows people to indicate the manner in which they want to die

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What are the 4 types of advanced directives?

DNR (do not resuscitate) or No code
Living will
Durable power of attorney for health care (AKA health care proxy)
Oral advance directive

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What is a DNR?

Physician’s order in Pt record indicating desire not to be revived if heart or breathing stops

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What is a living will?

Direction to physicians on how to treat you if you are to develop a persistent vegetative state

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What is a durable power of attorney/ Health Care Proxy)?

Designation of a surrogate decision maker (one person acts as another individual’s will)

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What is an oral advance directive?

Tell physician and family what you would want in given situations (should be documented in medical record)

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Why are advanced directives often ignored by professionals and family members?

Culture says lets do everything possible

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How is a DNR obtained?

Physician can post per direction of patient/ guardian

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How is a Living Will/ Durable power of attorney obtained?

Through department of health

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How can an advanced directive be obtained during a hospitalization?

Federal patient self-determination act

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Who most needs an advanced directive?

Young individuals who do not expect to die, and are then unexpectedly presented with their decision

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What are 9 ways to confidently conduct yourself with a dying patient?

Call cancer a “chronic condition”/ be aware of terminology
Confident bedside manner
Self-awareness of own feelings
Listen actively to the patient
Ask, don’t assume
Let patient set tone of conversations
Touch the patient
Be honest, hopeful, realistic, & positive
Do not isolate

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What is medically futile care?

Life-prolonging interventions with no chance to achieve a beneficial outcome, only prolong life.

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What is euthanasia?

INTENTIONAL killing by act or omission of a dependent human being for his or her alleged benefit.

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What is voluntary euthanasia?

When person who is killed has requested to be killed

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What is non-voluntary euthanasia?

When person who is killed made no request and gave no consent AKA homicide

What is involuntary euthanasia?

Person killed expressed wish to the contrary

What is assisted-suicide?

Some provides individual with information guidance and means to take his or her own life with the intention that they will be used for this purpose

What is physician assisted suicide?

Doctor helps another person kill themselves

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 care or food or water

What is assisted suicide according to Purtilo?

- Physician provides means - Physician necessary but not sufficient - Patient has active role

What is medically administered euthanasia according to Purtilo?

- Physician commits act by medical means - Physician necessary and sufficient - Patient's illness provides context for act

What is palliative care?

- Supportive care to prevent and relieve pain and other symptoms during the dying process - Helps patients and loved ones deal with their own death more realistically

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 not cure or treat intensively

What 4 states have physician assisted suicide legalized? (via legislation? via court ruling?)

Via leg: OR, VT, WA | Via court: Montana

How many states consider physician assisted suicide illegal?

Since there are no federal laws on assisted suicide, how is it enforced?

Via homicide laws

What are characteristics of individuals who got prescriptions for physician assisted suicide?

- White - + 65 yo - Well educated - Cancer diagnosis - Hospice enrolled - Health insurance - End of life concerns - Diagnosis of cancer

What were the 3 end of life concerns that lead to physician assisted suicide?

- Loss of autonomy - Not participating in activities that made life enjoyable - Loss of dignity

What was the median days between 1st request of asst suicide and death?

What was the range of days between 1st request and suicide?

15 - 692

What 3 countries is assisted suicide legal for adults in Europe?

- Belgium - Netherlands - Luxembourg

What European country allows for euthanasia of children older than 12 in some circumstrances?

Netherlands

What european country allows any incurably sick child to request to end their suffering if concious and equipped with capacity of discernment?

Belgium

What type of informed consent was used in Karen Quinlan's case in 1976? What was the fundamental criterion?

- Substituted judgment (father for hers) | - Medical prognosis (will patient get better?)

What type of consent was used in Saikewicz's case in 1976? What type of advanced directive was developed as a result of the case?

- Institution acted as guardian, and had profoundly mentally challenged man that developed leukemia - No code order

What resulted from the the case of Conroy in 1985?

- Nephew's "substituted judgement" of wanting the feeding tube removed from his uncle was overruled. - An objective standard needed to be used: "burdens... clearly & markedly outweighing the benefits"

What resulted from the case of O'Connor in 1988?

- Similar situation to Conroy in which nothing less than unequivocal proof of a patient's wishes would suffice when the decision to terminate life support was at issue

What was the first case on critically ill patients that was heard at the US Supreme Court?

Cruzen

What was the result of the Cruzen case in 1990?

- Missouri court required clearn & convincing evidence | - US Supreme Court upheld states's rights to set their own standards indicating inconsistencies among states is OK

What was the result of the Schaivo case in 2005?

- 36 yo female was in persistent vegetative state, but parents tried to stop husband from removing feeding tube - Husband decided to have right to make the decision

What is an end of life team?

- Assist patient and health care delivery team in dealing with patients who are dying and are close to death

What cultural issue may affect individual's perspectives on critically ill & dying patients?

Spirituality/ religion