DIGNITY IN DEATH

AND DYING

BY: SHING MAMAWAG

B.DIGNITY IN Euthanasia and Prolongation of Life

DEATH AND Inviolability of Human Life

DYING Euthanasia and Suicide

Dysthanasia

Orthothanasia

• Administration of Drugs to the Dying

• Advance Directives
• DNR or End of Life Care Plan
 Life, Death and Dying
Aggressive Life Less Aggressive Life
▪When a person is dying and Sustaining
Measures
Sustaining Measures
there is no expected
improvement in the patient’s condition, decisions have
to be made to start, stop, or withdraw life sustaining Mechanical ventilation Antibiotics
measures ,(Johnstone 2004,
p. 294). Surgery Blood transfusions

▪Who decides and when do these measures get

CPR Intravenous/gastric tube
hydration
stopped?
Hemodialysis Cardiac arrhythmic drugs

Chemotherapy
Euthanasia and Prolongation of Life
Euthanasia and assisted suicide are generally considered
medical procedures that should not be delegated to nurses.
However, nurses have been involved directly with aiding
someone to die or have been witness to it simply because of
providing end of life care to patients.
Furthermore, as nurses, you may decide one day to travel and
work in another part of the world.
It is important, therefore, to know about, contemplate, and
formulate your own thinking concerning the ideas and ethics
around euthanasia and assisted suicide.
 Not prolonging life?
➢ Figuring out when life prolonging interventions are no longer of
benefit to the patient, and relating this to the patient and family,
are difficult situations for health care professionals.
➢ What may be helpful in this circumstance is to agree to a
specified period of time to try aggressive treatment. If no
improvement is seen or the patient is deteriorating at the end of
this time period, then interventions are deemed futile* and are
stopped.
➢ In this way, the patient and the family are assured that all has
been done to assist the patient.
 Inviolability of Human Life
✓According to the sanctity of life principle, life is of intrinsic value.
Grounded in mainstream Christian beliefs, this principle prohibits
intentional killing—in both active and passive forms. Life is
considered a stewardship or loan from the Creator, and the
power to live or die resides with the Creator alone.
✓According to the qualified sanctity of life principle, one cannot
actively and intentionally hasten death; however, one can
refrain from preventing natural death. Treatment can,
therefore, be
omitted, allowing death to occur “naturally.”
 Inviolability of Human Life
✓The quality of life principle, in sharp contrast, permits
intentionally hastening death using either acts of omission
(withholding or withdrawing treatment) or commission
(prescribing overdoses or administering lethal injections).
Although the quality of life principle is now the dominant
ethos, its acceptance unfolded gradually over time. This
occurred largely in response to shifting public attitudes
towards intentional death, as reflected in legal documents
and case law.
 Definition of Euthanasia
The term euthanasia comes via New Latin from Greek
eu : (meaning easy, happy or good)
thanatos: (meaning death)
it is translated literally as ‘good death’ or ‘happy death’.
Contemporary English definitions of euthanasia vary.
The action of inducing a quiet and easy death
The act of killing someone painlessly, especially to relieve suffering from an
incurable illness’.
An act or practice of painlessly putting to death people suffering from
incurable conditions or disease’.
Basic Terms:
Euthanasia – the deliberate killing of a person for the benefit of that person.
Assisted Suicide – a situation where the person is going to die, needs help to
kill themselves, and asks for it. A qualified medical practitioner supplies the
patient with the means. The patient kills him/herself. It may be as simple as
getting drugs for the person and putting them within reach.
Mercy Killing – often used interchangeably with euthanasia, however, the
killing may be done without the patient request or consent.
An example, a father kills his cerebral palsy child by suffocating her; done to relieve
prolonged pain and suffering, sacrifice, and/or financial ruin for the child and the father.
Suicide – an act where a person deliberately plans and follows through on
taking their own life.
Palliative Care – medical, emotional, and spiritual care given to a person
which is terminally with the aim as reducing suffering and not curing.
(www.bbc.co.uk)
 Euthanasia
Beauchamp and Davidson (1979) argue that for an act to be an
instance of euthanasia, it must satisfy at least five conditions:
1. Intentionality. Death must be intended and not be merely
accidental, and further must be intended by at least one other
human being.
2. Suffering and evidence of suffering. Here suffering may be in the
form of conscious pain, mental anguish, and/or serious self-
burdensomeness (as may occur in cases of high quadriplegia, or
tetraplegia, or the like).
3. Reasons for death and the means of death. death-causing acts
must be motivated by beneficence or other humanitarian
considerations (such as the demand to end suffering).
 Euthanasia
4. Painlessness. This condition is related to the previous
one and demands, quite simply, that any death act
performed must be as painless and as merciful as
possible.

5. Non-fetal humanity. Beauchamp and Davidson contend

that if this simple qualification is not included then we
would not be able to distinguish acts of abortion from
acts of euthanasia.
Euthanasia & assisted suicide
Orthothanasia – letting the incurably diseased
person “die his own death’ while making no
extra efforts to prolong his life.
Passive Euthanasia – refraining of any medical
treatment aimed at retarding death
Active Euthanasia – terminating a person’s life
in a painless way, at his request & with the
intention to prevent person from suffering.
 Dysthanasia
- is the term for futile or useless treatment,
which does not benefit a terminal patient. It is a
process through which one merely extends the
dying process and not life per se. Consequently,
patients have a prolonged and slow death,
frequently accompanied by suffering, pain and
anguish.
Death & Advance refusals of Treatment
Apparent Death – the cessation of life as indicated
by the absence of all vital functions
Legal Death – the total absence of activity in the
brain and central nervous system, the
cardiovascular system, & the respiratory system
as observed and declared by a physician.
Criterion
Do-not-resuscitate orders
Why would someone want euthanasia or assisted suicide?
In most cases,

The person is terminally ill

Their quality of life is severely damaged
There is no hope of recovering from their illness
They fear loss of control or of dignity
They fear severe pain and suffering
They dislike being dependent or a burden
 Views to Support Euthanasia/Assisted Suicide
1. Right to Choose - A person has the right to self-determination which
includes the right to decide to choose death and at a time suitable for
him/her. It is their own body.
2. Right to Die with Dignity - A person should be permitted to die with dignity
and without pain. Medical advances that prolong life, but erode a person’s
self-esteem, character, and self-worth seem inhumane.

3. Right to Justice/Fair Treatment - It is wrong to make people live longer than

what they want, to become a burden to themselves and others, and to suffer
intolerably. If we do so, we are violating their personal freedom and human
rights.
4. Reduction of Suffering - People ought to be spared intense, prolonged, and
intractable suffering. It would seem merciful to end their suffering and cruel
to deny them a choice of death.
 Arguments Against Euthanasia/Assisted Suicide
1. Autonomy – Euthanasia on the grounds of patient autonomy
disregards the rights of and harmful effects for others,
specifically family and friends, medical professionals and
other carers.
2. Right to Die with Dignity – The right to die with dignity might
equally include respect for the person’s wish to have
everything medically possible done and to sustain a sense of
hope.

3.Right to Justice/Fair Treatment – To deny treatment to a

person based on the notion of it prolonging a hopeless life is
unfair. What is in the best interests of the patient may be to
have “everything possible done” which supports the meaning
and value of life only the patient can assign.
 Arguments Against Euthanasia/Assisted Suicide
4. Clinical Uncertainty – Once euthanasia is performed it is
irreversible. Diagnoses can be uncertain, and incorrect.
Sometimes patients do recover spontaneous from life
threatening illnesses and there is always hope of cures being
found.
5. Risk of Abuse – Euthanasia/assisted suicide would be abused
by doctors who might stereotype patients as unworthy of
saving or might not consult the patient and family at all about
end of life decisions. There is fear of abuses by family members
who might benefit from a loved ones death and use coercion to
get them to request euthanasia when they don’t really want it.
Regulation of euthanasia/assisted suicide is too difficult to
control.
 Arguments Against Euthanasia/Assisted Suicide
6. Non-Necessity – Palliative care makes euthanasia/assisted
suicide unnecessary.
7. Devalues Lives – Euthanasia/assisted suicide suggests that
some lives (i.e.. severely disabled newborns, severely brain
injured persons, people with end stage Alzheimer’s) are not
worth living. It also exposes vulnerable people, who may feel
themselves a burden, to pressure themselves into asking to
end their lives.
8. Sanctity of Life - This argument contends that life is sacred and
must not be taken. Religions draw heavily on the sanctity of life
argument. Most religions disapprove of euthanasia/assisted
suicide and some absolutely forbid it.
 Arguments Against Euthanasia/Assisted Suicide
9. “Slippery Slope” Argument - Many people worry that if
we permit (make legal) euthanasia for consenting
persons, inevitably we will then relax our moral
standards and let euthanasia be practiced on non-
consenting persons such as “infants, the mentally
impaired, demented, brain injured, dependent, frail,
elderly, and simply the unhappy” (Oglivie & Potts 1994
as cited in Johnstone 2004, p. 250).
 Should the Nursing Profession Take a Stand
on Euthanasia?
According to Dierckx de Casterlé, B., et al., nurses' involvement
starts when the patient requests euthanasia and ends with
supporting the patient's relatives and healthcare colleagues after the
potential life terminating act. Nurses stressed the importance of
having an open mind and of using palliative techniques, also
offering a contextual understanding of the patient's request in the
decision-making process. Concerning the actual act of performing
euthanasia, palliative care nurses saw their role primarily as
assisting the patient, the patient's family, and the physician by being
present, even if they could not reconcile themselves with actually
performing euthanasia.
Administration of Drugs to the Dying
Palliative care works to achieve one of the primary
goals of healthcare—relief of symptoms.
Palliative care is an option for patients who are
seriously or terminally ill. It focuses on achieving
the best possible quality of life for a patient by
emphasizing total and comprehensive care for all a
patient’s needs: pain and symptom management,
spiritual, social, psychological, and emotional well
being.
Administration of Drugs to the Dying
A study found that morphine, midazolam and haloperidol
were the most frequently prescribed drugs at the day of
death for patients in the largest palliative care centre in
the Netherlands (Masman, A. D., et al).
These drugs are given to relieve symptoms such as pain,
restlessness and agitation, which are frequently seen in
advanced cancer.
Palliative care supporters believe that failing to address the
suffering of a patient with a terminal illness violates two of
the main ethical principles behind health care:
1) Providing help or benefit to a patient (beneficence) – Failing
to relieve pain and other symptoms does not help the dying patient.
2) Not harming a patient (non-maleficence) – Failing to relieve
pain and other symptoms can actually harm a patient and the
patient’s loved ones.
For dying patients, palliative treatment provides relief of
suffering from pain and other symptoms.
 Withdrawal Vs. Withholding Treatments
▪ What is the difference between the two terms?
▪ Are they ethical? Are they legal?
Definition of terms:
Withholding treatment is the act of not instituting measures that
would serve to either prolong life or delay death.

Withdrawing treatment is defined as the removal or discontinuation

of life-sustaining/life-prolonging therapies of a treatment
considered medically futile in promoting an eventual cure or
control of disease or symptoms (Lesage & Latimer, 1998;
Sulmasy, 1998).
 Common Reasons for Withholding/Withdrawing
Therapy
1. Patient choice
2. Burdens outweigh benefits
3. Undesirable quality of life
4. Prolonging the dying process
Pearl for practice:
▪ Health care professionals may find it difficult to stop life-sustaining treatment
because they have been trained to do everything possible to support life
▪ Withdrawal or withholding treatment is a decision/action that allows the disease to
progress on its natural course. It is not a decision/action intended to cause death.
What is an advance directive?
An advance directive is a document that tells your
health care provider and family what kind of
medical care you'd want (or wouldn't want) if
you become terminally ill and can't speak for
yourself. An advance directive takes
effect only if you can't express your
wishes (for example, if you're in a coma).
Types of Advance Directives
✓ The living will. ...
✓ Durable power of attorney for health
care/Medical power of attorney. ...
✓ POLST (Physician Orders for Life-Sustaining
Treatment) ...
✓ Do not resuscitate (DNR) orders. ...
✓ Organ and tissue donation.
DNR or End of Life Care Plan
‘Do Not Resuscitate’ (DNR) Directive
➢ To deal with the moral and legal issues that arise in
performing CPR on hopeless medical cases, some countries
and health care facilities have implemented the ‘Do Not
Resuscitate’ directive.
➢ This directive states that “in the event of a cardiac arrest,
doctors, nurses, and other health personnel are not to
perform basic or advanced life support” (Cushing 1981, &
Honan 1991 as cited in Johnstone 2004, p. 297)
➢ This directive is written by doctors to prevent CPR abuses in
cases where the doctor judges the person’s disease to have a
hopeless prognosis. but what does that mean?
 Should the Nursing Profession Take a Stand
on Euthanasia?
According to Dierckx de Casterlé, B., et al., nurses' involvement
starts when the patient requests euthanasia and ends with
supporting the patient's relatives and healthcare colleagues after the
potential life terminating act. Nurses stressed the importance of
having an open mind and of using palliative techniques, also
offering a contextual understanding of the patient's request in the
decision-making process. Concerning the actual act of performing
euthanasia, palliative care nurses saw their role primarily as
assisting the patient, the patient's family, and the physician by being
present, even if they could not reconcile themselves with actually
performing euthanasia.
Administration of Drugs to the Dying
Palliative care works to achieve one of the primary
goals of healthcare—relief of symptoms.
Palliative care is an option for patients who are
seriously or terminally ill. It focuses on achieving
the best possible quality of life for a patient by
emphasizing total and comprehensive care for all a
patient’s needs: pain and symptom management,
spiritual, social, psychological, and emotional well
being.
Administration of Drugs to the Dying
A study found that morphine, midazolam and haloperidol
were the most frequently prescribed drugs at the day of
death for patients in the largest palliative care centre in
the Netherlands (Masman, A. D., et al).
These drugs are given to relieve symptoms such as pain,
restlessness and agitation, which are frequently seen in
advanced cancer.
Palliative care supporters believe that failing to address the
suffering of a patient with a terminal illness violates two of
the main ethical principles behind health care:
1) Providing help or benefit to a patient (beneficence) – Failing
to relieve pain and other symptoms does not help the dying patient.
2) Not harming a patient (non-maleficence) – Failing to relieve
pain and other symptoms can actually harm a patient and the
patient’s loved ones.
For dying patients, palliative treatment provides relief of
suffering from pain and other symptoms.
 Withdrawal Vs. Withholding Treatments
▪ What is the difference between the two terms?
▪ Are they ethical? Are they legal?
Definition of terms:
Withholding treatment is the act of not instituting measures that
would serve to either prolong life or delay death.

Withdrawing treatment is defined as the removal or discontinuation

of life-sustaining/life-prolonging therapies of a treatment
considered medically futile in promoting an eventual cure or
control of disease or symptoms (Lesage & Latimer, 1998;
Sulmasy, 1998).
 Common Reasons for Withholding/Withdrawing
Therapy
1. Patient choice
2. Burdens outweigh benefits
3. Undesirable quality of life
4. Prolonging the dying process
Pearl for practice:
▪ Health care professionals may find it difficult to stop life-sustaining treatment
because they have been trained to do everything possible to support life
▪ Withdrawal or withholding treatment is a decision/action that allows the disease to
progress on its natural course. It is not a decision/action intended to cause death.
What is an advance directive?
An advance directive is a document that tells your
health care provider and family what kind of
medical care you'd want (or wouldn't want) if
you become terminally ill and can't speak for
yourself. An advance directive takes
effect only if you can't express your
wishes (for example, if you're in a coma).
Types of Advance Directives
✓ The living will. ...
✓ Durable power of attorney for health
care/Medical power of attorney. ...
✓ POLST (Physician Orders for Life-Sustaining
Treatment) ...
✓ Do not resuscitate (DNR) orders. ...
✓ Organ and tissue donation.
DNR or End of Life Care Plan
‘Do Not Resuscitate’ (DNR) Directive
➢ To deal with the moral and legal issues that arise in
performing CPR on hopeless medical cases, some countries
and health care facilities have implemented the ‘Do Not
Resuscitate’ directive.
➢ This directive states that “in the event of a cardiac arrest,
doctors, nurses, and other health personnel are not to
perform basic or advanced life support” (Cushing 1981, &
Honan 1991 as cited in Johnstone 2004, p. 297)
➢ This directive is written by doctors to prevent CPR abuses in
cases where the doctor judges the person’s disease to have a
hopeless prognosis. but what does that mean?
 DNR Meaning
• Do Not Resuscitate (DNR) order is a part of advanced medical
directives allowed by federal law passed in 1991, expanding the
notion of patient autonomy to situations in which they may not be
able to make crucial medical decisions due to incapacitation.
• It instructs medical personnel not to perform life-saving (CPR) or
other procedures to restart the heart or breathing once they have
ceased and with the purpose of such advanced cardiopulmonary
techniques, it is possible to keep almost any patient's heart and lungs
functioning, independent of how terminal or hopeless
• Description: DNR orders affect a small group of patients and are
designed to avoid the suffering of a terminal illness or other serious
conditions that are medically irreversible.
• Reference: Death and Dying." In Merck Manual, Home Edition. [cited May 5,
2003]. http://www.merck.com/mrkshared/mmanual_home/sec1/4.jsp
 DNR Meaning
▪Example: A patient with poor prognosis and life expectancy of 6
months, developed a respiratory arrest related to an allergic
reactions to certain food he has ingested, shall you perform CPR
for him in this case even if his chart was labeled DNR ?
• What do you think?
• Is his arrest related to his hopeless medical condition?
• Is it a reversible condition? how is that going to affect his life
expectancy?
 Specific Problems with DNR
Ethical Proponents of a DNR order would say that it is a legal and
reasonable directive; critics would argue that such an order is simply a
moral decision based on beliefs about the quality and sanctity of life
(Johnstone 2004).
Let’s look at some of these issues.
1. Quality of Life as Criterion:
The quality of life criteria, often used to justify withholding life sustaining
medical treatment such as DNR, it is controversial because of the variety of
personal meanings assigned to quality of life.

One definition of quality of life is “the capacity or potential capacity to have

human relationships/to pursue human purposes/to live life independently.”
Johnstone 2004, p. 312).How this definition gets interpreted is individual and
may change over time. ?
1. Quality of Life as Criterion
➢ How many of you assume a person who suffers a severe spinal cord injury
causing quadriplegia has a poor quality of life?

How many of you have said you would prefer to be dead if found in that
situation?

Interestingly, research has shown that the attitudes of health care professionals
toward quality of life following spinal cord injury to be more negative than
patients who had such an injury. For example:
✓ “18% of emergency health care workers imagined they would be glad to
be alive with a severe spinal cord injury; whereas, 92% of those who had a
true spinal cord injury were glad to be alive.

✓quality
17% of emergency health care workers anticipated an average or better
of life after the accident; whereas 86% of those who had a spinal
cord injury had an average or better quality of life.” (Gerhart et al. 1994 as
cited in Johnstone, 2004, p. 313).
 1. Quality of Life as Criterion
The danger this example illustrates is that health professionals
must not assume to know under what conditions quality of life is
possible and apply their own views on patients with devastating
injuries.
Likewise end of life treatment choices for one patient might be the
wrong choices for another patient in terms of their perception of
quality of life outcomes.
Health professionals must take care to understand what quality of
life means to patients and its relevancy to decisions about care
options.
Ultimately, the person whose quality of life is at issue, is the best to
judge what counts as being their quality of life!
2. Sanctity of Life Criterion
• If one respects sanctity of life in making end of life
treatment choices, even intolerable and intractable
suffering would not give cause to ending it.
• DNR would be considered wrong.
• Consider the 70 year old woman who was
resuscitated over 70 times in a few days
(Johnstone 2004, p.302).
• Is this action preserving sanctity of life?
3. Excluding Patients from Decision-Making
➢ Some health professionals and institutions believe that, in the
medically hopeless cases, patients should not be burdened with
the decision to resuscitate or not, even though the principle of
autonomy is highly regarded.
➢ Some claim that even if the patient wants CPR, if the doctor
warrants CPR as having no possible benefit to the patient, it
should not be initiated.
➢ Excluding patients and their families from the decision of DNR
may cause unnecessary suffering to patients (who survive) and
their families who want doctors and nurses to try to save their
loved one.
4. No Code Does Not Mean No Care
• Sometimes DNR policies are misunderstood which can lead to
poor care.

• For example, Saunders and Valente (1986) describe a case where

a dying patient had copious amounts of secretions from
pulmonary congestion. The nurses misinterpreted the DNR order
to mean withholding suctioning and thus the patient was left
suffering and drowning in his secretions.

- Remember the issue of exact meaning of DNR?!

5. Documentation and Communication of DNR
• If DNR directives are given verbally, and not written in the patient’s chart,
this can lead to confusion and inappropriate action taken at the time of an
arrest.

- Nowadays according to JAHCO, DNR must be appropriately documented on

the chart or on a special form called advanced directives , and an informed
consent should be obtained, along with a witness, who might be a nurse
taking that role, or one of the family members.

DNR and the law:

➢ The practice of putting DNR policies in place in health care institutions really
started in the 1990’s and is increasing.
➢ The degree to which these policies are complied with is unknown and the
quality of the policies in providing direction varies widely (Johnstone 2004,
p. 297).
THANK YOU FOR LISTENING!