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Death 1981

answer

The irreversible cessation of circulatory and respiratory or neurologic functions One of these two criteria or both must be met for a physician to pronounce a person dead, either whole-brain death or cessation of circulatory or respiratory functions

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Death w/Advanced Technology

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A stand-alone criterion of whole-brain death, which is one of the two criteria of death

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Stand-Alone Criteria for Death

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Cessation of circulatory and respiratory functions

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DNC

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Death by updated and specific neurological criteria

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Yalom's definition of death

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A dread of death that resides in the unconscious A dread that is formed early in life at a time prior to the development of precise conceptual formation A dread that is terrible and inchoate and exists outside of language

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Death Anxiety

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An innate fear of death or nonbeing

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Death Avoidance Defenses

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1. Immortality Projects 2. Dependence on a rescuer

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Immortality Projects

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People throw themselves into commendable projects, their work or raising children People thoroughly and completely engage in these activities and by doing so, they attempt to insulate themselves from death

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Dependence on a rescuer

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Believing another person can provide a sense of safety or protection from the fear of death

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Spiegel's Death Study

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A large study about death and dying Several hundred people discussed their greatest fears about death

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Good Death

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People do not allow medical care and treatment to control all their thoughts about their death, rather they focus on the illness trajectory and the best palliative care they can receive

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Dame Cicely Saunders

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A London nurse The Florence Nightingale of Hospice Started the concept of the Modern Hospice Movement "the suffering of the dying is total pain with physical, emotional, spiritual and social elements" "The dying just want someone to care enough to try"

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Nancy Dubler

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Presented what she called a cinematic myth of the good American death

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Lehto and Stein

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Emphasized the significance of death anxiety and the role of nurses in everyday practice - Nurses need to take into account the possibility that some patients manifest ill effects or behaviors as a result of experiencing death anxiety

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Benefits of Envisioning an Ideal Death & Reflecting on it

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- Helps to develop a sense of readiness for a peaceful death

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John Dewey

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- An American Philosopher - Described a moral framework based on a person's development of intelligent habits through an imaginative dramatic rehearsal

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Imaginative Dramatic Rehearsal

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Imagining an ideal scenario (such as an ideal death) to take meaning from the experience and shape how the scenario plays out in real life - A person can imagine one's own death by reconstructing the ideal death scenario - On continued reflection, they may later discover a rich, meaningful experience through this imagination - Persons who imagine an ideal death have a greater possibility of finding significance at the end of their lives and then, to some extent, shape their dying process.

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Chronic Disease

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An illness that is generally characterized by multiple etiologies, a long-lasting course, and no cure, but it is often manageable

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Hester on Suffering

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Emphasized that healthcare professionals should not reduce the concept of suffering to pain "When we speak of suffering we mean far more than pain"

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Kahn and Steeves on Suffering

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An individual could experience suffering following a sense of threat to the being, the self and existence

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Eric Cassell

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- Emphasized that suffering involves the whole person and body, but pain and suffering are separate phenomena - Made a connection between human suffering on the individual level and a person's need for compassion. - Nurse's mindfulness of this connection can enrich their comprehension of patient suffering - Nurses can begin the journey of comprehending other's suffering through the context of having compassion - Nurses use strategies such as empathy, compassion and attentive listening to console suffering patients

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Eriksson definition of Suffering

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A perceived undesirable inner experience that could threaten the whole existence of being, yet it is a necessary element of life, as are joy and happiness If others show compassion toward a suffering person, one could develop a more meaningful suffering existence

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Stan van Hooft

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At the forefront of studying the Aristotelian framework of the human soul as a way to explain human suffering - Suffering is the opposite of flourishing - Because pain is a hurtful and unpleasant sensation with varying intensities and degrees, it can interfere with individual's achievement of a flourishing life and therefore will lead to suffering - Pain is a result of a malady or an illness of the vegetative or bodily state - Pain can steal joy, contentment and happiness and can cause individuals to suffer and lose a passion for life - Suffering saturates the whole body in all its four parts

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Aristotle view of Suffering

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A soul consists of a being with physical and spiritual interconnections The being has 4 inseparable parts: 1. Vegetative: nonrational biological functions 2. Appetitive: nonrational desires and the striving for attaining desires 3. Deliverative: mostly rational and reasoned strategic thinking about how to fulfill self-goals 4. Contemplative: a fully rational soul, the spiritual part, and thinking about the things that are unchangeable about the meaning of one's existence and the spiritual soul Each of these 4 parts has their own goal/telos, but as interconnected and inseparable parts of a whole being, they have one purpose: Eudaimonia (happiness, human fulfillment, and flourishing) If one part cannot reach this would-be goal, the whole being suffers because the mind and body are inseparable insofar as these 4 parts are concerned

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Catherine Garrett on Suffering

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- Life's work was on the differentiation of pain from suffering - Describes the suffering person as a tormented being - Suffering is an inevitable but unwelcome component of experiencing life - Suffering is no only subjective, it is also objective in the sense that a suffering person's symptoms can become recognizable signs to others (i.e a person experiencing death and dying, a chronic illness or chronic violence)

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Nurse Responsibilities Toward Suffering Patients

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- Interpret the suffering of their patients in an attempt to alleviate or minimize pain or distress - ANA: Nursing encompasses the protection, promotion and restoration of health and well-being; the prevention of illness and injury; and the alleviation of suffering in the care of individuals, families, groups, communities and populations - NCLEX: The goal of nursing is preventing illness, alleviating suffering, protecting promoting and restoring health and promoting dignity in dying - ICN: Nurses have 4 fundamental responsibilities: to promote health, to prevent illness, to restore health and alleviate suffering

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Compassion

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An understanding and recognition of suffering, along with an honest desire to alleviate said suffering

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Attentive Listening

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Actively paying attention to what is being said; techniques include focusing on the speaker, not interrupting the speaker and restating the speaker's thoughts to ensure that there has been no misunderstanding

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Euthanasia

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A good or painless death; the act of intentionally ending a life - often, though not always - with the goal of limiting or relieving pain and suffering - "mercy killing" - 2 Types: * Active Euthanasia * Passive Euthanasia Can also be: *Voluntary euthanasia *Nonvoluntary euthanasia

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O'Rourke

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Suffering in all its forms is an evil, and every reasonable effort should be made to relieve it

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Dr. Jack Kevorkian

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Argued strongly for euthanasia when patients were in a terminal state of dying - Assisted with 100+ suicides or mercy killings - Nicknamed "Dr. Death" - Convicted of 2nd degree murder and served 8years in prison * in 1988 he was televised assisting in the lethal injection of Mr. Youk, age 52 who was dying of Lou Gehrig's disease - this was considered active euthanasia, not physician-assisted suicide

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Active Euthanasia

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- The intentional and purposeful act of causing the immediate death of another person, whether or not the dying person requested it i.e. a person with a terminal illness or a painful disease, or a person who cannot be cured - Dr. Kevorkian did this with Thomas Youk on national television - Is not widely accepted like passive euthanasia

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Physician-Assisted Suicide

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Taking one's own life via self-administration of physician-ordered drugs - 4 states allow this: Oregon, Washington, Vermont, Montana

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Passive Euthanasia

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The intentional withholding or withdrawing of medical or life-sustaining treatments AKA: "letting go" Has become widely accepted today

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Voluntary Euthanasia

answer

When patients with decision-making capacity authorize physicians to take their lives - Associated with "physician-assisted suicide"

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Nonvoluntary Euthanasia

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When persons are not able to give express consent to end their lives and are unaware they are going to be euthanized i.e. a physican could euthanize a patient when a family member who serves as a decision maker gives consent

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Involuntary Euthanasia

answer

A person's consent may be possible but is not sought, and a physician could euthanize someone without express consent i.e. euthanizing of a death-row inmate

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Battin

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- Wrote "The Lease Worse Death" - Says Euthanasia is morally right and humane on the grounds of mercy, autonomy and justice

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Principle of Mercy/Mercy Killing

answer

Includes 2 obligations: 1. the duty not to cause further pain and suffering 2. the duty to act to end existing pain or suffering

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Principle of Autonomy

answer

The idea that health professionals ought to respect a person's right to choose a suitable course of medical treatment.

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Principle of Justice

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How salvageable the providers of care believe a permanently unconscious person to be

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Salvageability/Unsalvageabilty Principle

answer

Based on this principle, a healthcare provider could justify performing Euthanasia on still-competent but dying patients if they were regarded as unsalvageable - Knowing where to draw the legal and moral line with this principle that providers and families may face difficult decisions

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Stethoscope

answer

Invented in 1819

question

EKG

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Invented in 1903 Invented by Willem Einthoven, a Dutch physician

question

Determination of Death

answer

19th -20th Century: when the heart stopped beating and the person stopped breathing 1950s-60s: uncertainty involving death caused to keep patients alive in the absence of a natural heartbeat 1960s-1970s: transplants were being performed and a diagnosis of death would not necessarily depend on the absence of a heartbeat and respirations. Going forward the definition would need to include brain death criteria

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Harvard Medical School

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In 1968 attempted to redefine death not only rain death in terms of heart-lung cessation - they added reliable brain death criteria for ventilator-dependent patients with no brain function (i.e. patients in an irreversible coma) - Death came to mean the traditional heart-lung death and a new kind of death called brain death

question

Defining Death Document of 1981

answer

- A body was an organism as a whole - Three organs: heart, lungs, brain assume significance because their interrelationship is very close and the irreversible cessation of any one very quickly stops the other two and consequently halts the integrated functioning of the organism as a whole. - Because they were easily measured, circulation and respiration were traditionally the basic "vital signs". - Breathing and heartbeat are not life itself. They are simply used as signs - as one window for viewing a deeper and more complex reality: a triangle of interrelated systems with the brain at its apex - A person who is dead has sustained either of the following: * irreversible cessation of circulatory and respiratory functions * irreversible cessation of all functions of the entire brain, including the brain stem

question

3 Standards for Death

answer

- Cardiopulmonary Death: a person is dead when the cessation of breathing and heartbeat is irreversible - Whole-brain Death or Permanent Brain Failure: irreversible cessation of all brain functions, with no electrical activity in the brain, including the brain stem - Higher-brain Death: irreversible cessation of the capacity for consciousness, which implies that the person is dead even though the continual function of brain stem regulates breathing and heartbeat (such as in persistent vegetative state)

question

EEG

answer

- Electroencephalogram - A meter used to measure the electrical activity of the brain - Needed if a person is on life-sustaining support while in the process of being pronounced dead (i.e. whole-brain death) - One is usually sufficient in the US, but some jurisdictions require two: performed 24hrs apart that show no brain activity - Nurses and physicians must make certain that loss of brain function is not due to mind-altering medications, hypoglycemia, hyponatremia or any other cause

question

Persistent Vegetative State (PVS)

answer

Patients with a higher-brain death or loss of higher brain function live indefinitely but without the need for mechanical ventilation - Patient with higher-brain death may have lost some but not all functions, which has been the cause of enormous dispute - Even minimal brain functioning (i .e. limited reflexes in the brain stem) is cause for a patient to be diagnosed with Higher-Brain death

question

Uniform Determination of Death Act of 1981 (UDDA)

answer

The legal definition of death

question

Advance Directives

answer

A written expression of a person's wishes about medical care, especially care during a terminal or critical illness - when they have lost control over their lives - when they have lost their decision making capacity Instructions about their future health care for others to follow Can be self-written instructions or prepared by someone else as instructed by the patient There are 2 types: - Living Will - Durable Power of Attorney Can be a source of comfort for patients and families as long as they realize their limitations and scope

question

Patient Self-Determination Act of 1990

answer

Laws to protect the rights of individuals making decisions about end-of-life and medical care

question

Advance Directive Checklist

answer

- Specific treatments to be refused or administered - The time the directive needs to take effect - Specific hospitals and physicians to be used - Which lawyer, if any should be consulted - Specific other consultations such as ethics team, chaplain or a neighbor

question

Living Will (began in 1960s)

answer

A formal legal document that provides writing directions concerning what medical care is to be provided in specific circumstances case - Karen Ann Quinlan case in 1970s brought public attention to living wills and prompted legislation of it - Problems: * vague language * only instructions for unwanted treatments * lack of a description of legal penalties for those people who choose to ignore the directives of a living will and are legally questionable as to their authenticity

question

Durable Power of Attorney

answer

A legal written directive in which a designated person can make either general or specific healthcare and medical decisions for a patient - Has the most strength for facilitating healthcare decisions Weaknesses: - However, even with a POA, families and HCPs may experience fear about making the wrong decisions regarding an incapacitated patient - Very few people every complete ad advance directive - A surrogate decision maker may be unavailable for decision making and HCPs cannot overturn advance directives if a decision needs to be made in the best interest of the patient

question

Nurses and Advance Directives

answer

- Ensuring their validity - Realizing the importance of preserving patients from unwanted intrusive interventions - Respecting the possibility that patients may change their minds about their expressed written wishes The all demonstrate benevolence toward patients and their families

question

Surrogate Decision Maker

answer

AKA: A Proxy An individual who acts on behalf of a patient - Is either chosen by the patient (i.e a family member) - Is court appointed - Has other authority to make decisions Family members serving as proxies are generally referred to as surrogates There are 3 types of surrogate decision-making standards: 1. substituted judgment standard 2. pure autonomy standard 3. best interests standard

question

Surrogate Challenges

answer

- Decisions about treatment options and motives behind decisions may be complex and destructive - There needs to be appropriate dialogue between physicians, nurses and surrogate before the surrogate makes decisions - Endure an uncomfortable multistage decision-making process for gathering information and engaging the patient (when possible), extended family, physicians, nurses and other HCPs - Sometimes have difficulty distinguishing between their own emotions and the feelings of others - May have monetary motives for making certain decisions *nurses and physicians must be alert to these kinds of motives or concerns and look for therapeutic ways to deliberate with the surrogate

question

Substituted Surrogate Standard

answer

Used to guide medical decisions for formerly competent patients who no longer have any decision-making capacity - Based on the assumption that incompetent patients have the exact same rights as competent patients to make judgments about their healthcare - Surrogates make medical treatment decisions based on what they believe patients would have decided if they were still competent and able to express their wishes - Surrogates use their understanding of the patient's overt or implied expressions of their beliefs and values

question

Pure Autonomy Standard

answer

Based on a decision that was made by an autonomous patient while competent but who later drifted into incompetency - The decision is usually upheld based on the principle of autonomy extended

question

Best Interests Standard

answer

An evaluation of what is good for an incompetent patient in particular healthcare situations when the patient has probably never been competent, such as in the case of an infant or mentally retarded adult - the surrogate attempts to decide what is best based on the patient's dignity and worth as a human being without taking into consideration the patient's concept of what is good or bad. - Is patient centered and the surrogate must make decisions based on current and future interests

question

Futile

answer

Pointless or meaningless events or objects

question

Medical Futility

answer

The unacceptably low chance of achieving a therapeutic benefit for the patient - Questions to ask are related to Bioethics When a healthcare provider cannot have reasonable hope that a treatment will benefit a terminally ill person, the treatment is considered futile i.e CPR, medications, mechanical ventilation, artificial feeding and fluids, hemodialysis, chemotherapy, and other life-sustaining technologies - A second opinion is an essential component in declaring it

question

Schneiderman

answer

Linked his definition of medical futility to the whole person, similar to the way Aristotle spoke of a human being with four inseparable parts: - A suffering person will seek a cure, healing or care from a provider to become as whole as possible again

question

Concept of Futility

answer

- Nurse must understand how integral the suffering-healing-relationship is to the health process and the goals of medicine and nursing - The provider of care is responsible for administering medical treatments and interventions to benefit the patient as a whole and not just have a small effect on some part of the body or organ - There must exist the necessity of the patient to comprehend and appreciate the benefits of medical treatment * the person must be at least partially conscious: those in a vegetative state cannot do this - This movement became more important in 1970s

question

Landmark Cases in Medical Futility

answer

- Helga Wanglie, 1988 - Baby K, 1993 - Gilgunn vs Massachusetts General Hospital, 1995

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Palliative Care

answer

Comfort measures that patients may request instead of aggressive medical treatments when their condition is terminal - Nurses are the most active of all HCPs in meeting these needs of dying patients * understanding what quality of life means to the dying patient * do no hasten or prolong death, rather provide patients with relief from pain and suffering and help maintain dignity in the dying experience - An organized movement since 1990s - Treatment may include a patient's and family's choice to forgo, withhold or withdraw treatment

question

WHO definition of Palliative Care

answer

An approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual

question

Main Goals of Palliative Care

answer

- Prevent and relieve suffering - Allow for the best care possible for patients and families

question

Slow Code

answer

Going through the motions or giving half-hearted CPR to a patient whose condition has been deemed futile - Happens when a physician has not yet written the DNR order of a terminally ill patient - It is unethical and illegal and physicians and nurses should never initiate them - Are not recognized as a legal procedure

question

The Right To Die

answer

Based on the Principle of Autonomy A patient's choice Well informed patients with decision-making capacity have the right to refuse or forgo recommended treatments in an attempt to avoid a longer period of suffering during the dying process A person has an autonomous right to refuse life-sustaining or life-extending treatment measures Usually there are no ethical or legal ramifications if a person decides to forgo treatments HCPs need to make sure the patient's decision is truly autonomous and not coerced

question

Perceived Burden

answer

In the patient's mind the burdens of medical treatments outweigh the benefits Can include: - physical pain - emotional suffering - prolongation and dread of carrying out treatments - Economic, social and spiritual

question

Withholding and Withdrawing Treatment

answer

The foregoing of life-sustaining treatment that the patient does not desire, either because of a perceived disproportionate burden on the family or patient or for other reasons

question

Landmark Withholding & Withdrawing Cases

answer

1. Karen Ann Quinlan, 1975 2. Nancy Cruzan, 1983 3. Terry Schiavo, 2005

question

Clinical Diagnosis of Persistent Vegetative State Guidelines

answer

- No awareness of self or environment and inability to interact with others - No sustained, reproducible, purposeful or voluntary responses to visual, auditory, tactile or noxious stimuli - No language comprehension or expression - Intermittent wakefulness exhibited by the presence of sleep-wake cycles - Preserved autonomic functions to permit survival with medical and nursing care - Incontinence: bladder and bowel - Variable degrees of spinal reflexes and cranial-nerve reflexes (ie. pupillary, oculocephalic, corneal, vestibule-ocular and gag)

question

Conditional For Withdrawing Treatment

answer

- Patient has the right to refuse medical treatment - Artificial feeding constitutes medical treatment - When the patient is mentally incompetent, each state must document clear and convincing evidence that the patient's desires had been for discontinuance of medical treatment

question

Alleviation of Pain and Suffering in Dying Patient

answer

A primary responsibility of nursing and providers of care - ANA 2010 said nurses need to provide aggressive pain control for suffering patients at the end of life, but they should never have the intention of ending a patient's life

question

Rule of Double Effect/RDE

answer

An individual's reasoning that an act causing good and evil is permitted when the act meets the following conditions: - The act, considered independently of its evil effect, is not in itself wrong - The agent intends the good and does not intend the evil either as an end or as a means - The agent has proportionately grave reasons for acting, addressing his relevant obligations, comparing the consequences and considering the necessity of the evil, exercising due care to eliminate or mitigate it Attributed to St. Thomas' Aquinas writing about a person's self-defense in a homicide Inclusive of actions that could cause harm, which is a foreseen but inevitable outcome Of concern when the HCP sees some good in the action, yet foresees with certainty that there will be bad in the action

question

Terminal Sedation

answer

An accepted practice in the US and many other countries A last resort when a suffering patient is sedated to unconsciousness, usually through the ongoing administration of barbiturates or benzodiazepines The patient dies of dehydration, starvation or some other intervening complication as all other life-sustaining interventions are withheld The HC team discontinues medications and feeding tubes

question

Ira Byock

answer

States that Terminal Sedation does not hasten death and is only used in the last stages of life when medications and nutrition and hydration do not prolong life

question

Rational Suicide

answer

A self-slaying based on reasoned choice and is categorized as voluntary active euthanasia - the person has a realistic assessment of life circumstances, is free from severe emotional distress and has a motivation that would seem understandable to most uninvolved people in the person's community

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