End of Life Decision Making

Question 1

What are four principles of autonomy?

Answer 1

Freedom
Effective deliberation
Authenticity
Moral reflection

Question 2

What is “freedom” (as a principle of autonomy)?

Answer 2

Freedom to decide to act.

Question 3

What is “effective deliberation” (as a principle of autonomy)?

Answer 3

Effective deliberation - arrive at the conclusion through a process of rational reasoning, have necessary information.

Question 4

What is “authenticity” (as a principle of autonomy)?

Answer 4

Authenticity - Choice is consistent with the disposition/values and character of the person; pain and sickness may result in “out of character decisions”.

Question 5

What is “moral reflection” (as a principle of autonomy)?

Answer 5

Moral reflection - analyzing the moral consequences of their decisions.

Question 6

What is medical futility?

Answer 6

When benefit of certain treatment/interventions is so remote/limited that physicians may unilaterally decide not to offer them as feasible options or refuse them despite the patient’s or surrogate’s request.

Question 7

How does paternalism relate to end of life decision making?

Answer 7

Paternalism - who makes the decision or determines what is futile?

Question 8

What are four exceptions to the duty to provide life-sustaining measures?

Answer 8

Irreversible progression to imminent death.
Treatment which is clearly ineffective or harmful.
Instances where life will be greatly shortened regardless of treatment & where non-treatment will allow a greater degree of caring and comfort than treatment.
Lives filed with intolerable and intractable pain and suffering.

Question 9

What is “extraordinary treatment”?

Answer 9

Treatment that is not indicated for a patient on grounds of its proven or believed therapeutic effect, but which is appropriate to offer because it may chance to prolong life or alleviate distress.

Question 10

What is “ordinary treatment”?

Answer 10

Treatment routinely employed because it assists patients to survive or to cope with terminal suffering and to sustain life of human experience.

Question 11

What are some examples of “ordinary treatment”?

Answer 11

Blood transfusion for shortness of breath or lethargy
Pain control
Oxygen
Sedation
Palliative radiation

Question 12

What is voluntary euthanasia?

Answer 12

In accordance with the person’s wishes; unencumbered patient requests death (withholding or withdrawal of treatment).

Question 13

What is involuntary euthanasia?

Answer 13

Encumbered patient and decision based on substitute decision maker, best interest, advanced directive.

Question 14

What is passive euthanasia?

Answer 14

Action or omission, the intent of which is something other than death of the person eg. the relief of suffering but which will likely lead to death of the person (the next dose of morphine).
-The goal is to relieve suffering, death may be a by-product

Question 15

What is active euthanasia?

Answer 15

Action or omission, the intent of which is to hasten or cause the death of the person.

Question 16

What are two kinds of legal euthanasia in Canada?

Answer 16

Voluntary/passive (withhold or withdraw treatment) - Any unencumbered person can refuse treatment.
Non-voluntary/passive (withhold or withdraw treatment) - HCP can withhold or withdraw treatment if it is reasonable to do so.

Question 17

Is active euthanasia legal in Canada?

Answer 17

Illegal (this is when HCP intentionally delivers fatal dose).

Question 18

What are the two principles of passive euthanasia?

Answer 18

There is no morally significant difference between food, fluids, and medical treatment.
There is no morally significant difference between withholding and withdrawing life sustaining treatment.

Question 19

What are the laws in Canada regarding euthanasia?

Answer 19

‘No person is entitled to consent to have death inflicted on him, and said such consent does not affect criminal responsibility of any person by whom death may be inflicted on the person by whom consent is given’ ~criminal code: section 14

‘Nothing is in Section 14 shall be interpreted as requiring a physician to continue to administer or to undertake medical treatment against the expressed wishes of the person for whom such treatment is intended’ ~ Criminal Law reform commission 1982

‘Everyone who a) counsels a person to commit suicide or b) aids or abets a person to commit suicide whether suicide ensure or not , is guilty of an indictable offence and liable to imprisonment for a term not exceeding 14 years ~ Criminal Code & Aiding Suicide 241

Question 20

What are some arguments for active euthanasia?

Answer 20

Respect for autonomous decisions.
Prevention of suffering and respect of dignity.
If intention and the certainty of outcome are the same, is there morally relevant difference between killing and letting die?
Reduces the potential for iatrogenic suffering.
If suicide is not a criminal offense, is the assisting of one’s suicide under special circumstances any different?

Question 21

Which principles are affected by active euthanasia?

Answer 21

Beneficence - oblidation to do what is best for the patient.
Non-maleficence - do no harm
Autonomy - independence and choice

Question 22

What are some arguments against active euthanasia?

Answer 22

Thou shalt not kill.
Providential order of things - there is an allotted time to die and should not interfere.
One has a duty to others and ending one’s life breaches that duty.
Possibility of incorrect diagnosis or discovery of treatment.
Can we be absolutely sure that we have the patient’s voluntary and informed consent with no interfering factors?
Chronically and terminally ill often feel they are a burden to others.
“Slippery slope” argument - will this lead to active non-voluntary euthanasia?
Palliative care and pain control impacts will to live.

Question 23

What are the criteria for active euthanasia in The Netherlands?

Answer 23

Patient repeatedly and consistently, over a period of time, requests death.
Physician goes through full consultation with patient, family, and at least one other physician.
Patient’s suffering cannot be averted by an accepted medical treatment.
Illness is terminal, although death need not be imminent.

Question 24

What is MAiD according to CRNBC?

Answer 24

Purposeful and intended outcome is to assist a person explicitly requesting assistance in dying to end his or her life in a respectful, culturally appropriate, safe, ethical and competent manner.

Question 25

What is palliative care? (according to CRNBC)

Answer 25

Purpose is to improve the quality of life of a person experiencing a life-limiting illness. MAiD is not an appropriate alternative for a person who is seeking palliative care. While palliative care activities such as pain management or palliative sedation may result in the unintended hastening of death, the intended outcomes of these palliative care activities are to reduce intractable pain and extreme suffering at the end of life.

Question 26

What are the implications of MAiD for nursing care?

Answer 26

Provide a consistent care provider.
Be aware of the “reachable moment”.
Engage in active listening to defuse emotional buildup.
Focus on comfort and symptom management.
Make use of your power position, negotiation and mediation skills in times of conflict.
Promote discussion among all significant parties.
Keeping the parties informed, finding out about their “lived” experience and the dying experience.
In essence, hear their story and advocate on their behalf.

Question 27

How does Kant define dignity?

Answer 27

Dignity is a basic characteristic that all humans have because they can reason.
Never lose dignity, regardless of their capacity or incapacity to act (eg. persistent vegitative state or morphine enduced stupor would still have inherent dignity).

Question 28

How does Hayry define dignity? (utilitarian view)

Answer 28

Dignity is based on the capacity to feel pleasure/pain. I.e. it can be lost. Ex. persistent vegitative state and embryo’s do not have dignity.

Question 29

How does aristotle define dignity?

Answer 29

Dignity is the fulfillment of social roles.
Requires some independence and control.
Ex. persons with disability unable to fulfill social roles = lack dignity