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  1. 1. Chapter Nine Withholding and Withdrawing Life Support
  2. 2. Life Redefining the concept of life Biological life Living things Not uniquely human Biographical life Individual life events, desires, goals, memories
  3. 3. Standards for Death Cardiopulmonary standard Classic standard Loss of cardiac and pulmonary function
  4. 4. Standards for Death (continued) Brain death – irreversible cessation of all functions of the entire brain, including the brain stem Unreceptive and unresponsive No movements or breathing No reflexes
  5. 5. Brain Death – Clinical Problem Brain-dead patients are often very problematic to families Heart often in sinus rhythm Ventilator simulates breathing Patient may have the appearance of life Practitioners must shift concern from deceased patient to grieving families
  6. 6. Neocortical Death Some call for a new standard for death: The irreversible loss of higher brain function Many patients in persistent vegetative state would be judged to be dead
  7. 7. Neocortical Death (continued) The acceptance of a neocortical standard would necessitate additional movement toward active euthanasia, for which currently there is no societal consensus
  8. 8. Persistent Vegetative State PVS suggests irreversible loss of neocortical function Permanent eyes-open state of unconsciousness Generally brain stem continues to function, patient breathes, elicitable reflexes, reactions to external stimuli
  9. 9. Persistent Vegetative State (continued) PVS does not meet brain death criteria: Remote chance for recovery
  10. 10. Karen Ann Quinlan PVS patient: Family request Court decision and rationale Outcome Ordinary care vs. extraordinary care: What is the difference?
  11. 11. Ordinary Means All medicines, treatments, and operations that offer reasonable hope of benefit: Obtained without excessive expense Without excessive pain Without other inconvenience
  12. 12. Extraordinary Means All medicines, treatments, and operations that cannot be obtained or used without: Excessive expense Excessive pain Excessive inconvenience If used, would not offer reasonable hope of benefit
  13. 13. Ordinary & Extraordinary Means It is generally held that one can ethically forgo extraordinary means but is obliged to continue ordinary means of care If care offers no potential benefit, would it be by definition extraordinary? Could hydration and nutrition be considered extraordinary?
  14. 14. Proxy Decision-Making Standards Substituted-judgment standard: Person at one time capable of making decision Karen Ann Quinlan Best-interest standard: Person never in situation where an authentic choice could be made Joseph Saikewicz
  15. 15. Informed Nonconsent What is to be done when a competent adult, after having been informed in regard to their need for lifesaving care, refuses? William Bartling Elizabeth Bouvia
  16. 16. Informed Nonconsent (continued) Court Ruling: Patient acuity is irrelevant to the allowance of refusal Patient’s perception of his or her quality of life and treatment requirements are of paramount importance
  17. 17. Informed Nonconsent (continued) Court Ruling (continued): No meaningful legal distinction between mechanical life support and nasogastric feeding tube Distinctions between withholding and withdrawing care are legally irrelevant
  18. 18. Baby Doe Baby Doe case Interim Final Rule and “Baby Doe squads” Child Abuse Amendment guidelines Government ruling returns decision making to parents and physicians
  19. 19. Organ Donation Ongoing shortage Policy of volunteerism Uniform Anatomical Gift Act
  20. 20. Organ Donation (continued) Proposals for policy change Mandated choice Presumed consent Financial incentives Xenografting Changing definition of death Use of condemned prisoners
  21. 21. Organ Donation (continued) Review the case study – “Go Ahead and Cut Him” Does motivation matter? Does motivation affect the consent? Your decision?
  22. 22. Personhood Proposal Some have argued for personhood criteria to settle PVS cases: Only persons can be thought of as beings who possess rights
  23. 23. Personhood Proposal (continued) Personhood criteria: One who could be said to have interests One who has cognitive awareness One who is capable of relationships One who has a sense of futurity
  24. 24. Nancy Cruzan Nancy Cruzan case Court decision State has right to assert an unqualified interest in preserving human life Choice between life and death extremely personal (clear and convincing evidence) Incompetent patients subject to abuse
  25. 25. Nancy Cruzan (continued) Decision led to increased interest and use of advanced directives Hydration and nutrition question: When treatment is futile With no possibility of benefit
  26. 26. Nancy Cruzan (continued) In these cases, the court ruled that there should be no barrier to discontinuance Review and consider the case “A Question of Motivation”
  27. 27. Advanced Directives Living will statements: Hard to be inclusive for all situations Choice may change over time and change of circumstances (pregnancy) Durable power of attorney: Greater flexibility Combined forms Patient Self-Determination Act of 1990
  28. 28. Key Concepts Biological vs. biographical life Brain death Benefits and drawbacks to moving to a neocortical definition of death Best-interest and substituted-judgment legal standards to assist in proxy decision making
  29. 29. Key Concepts (continued) Advanced directives Living wills Durable power of attorney Court decisions regarding the right of competent adults to informed nonconsent
  30. 30. Key Concepts (continued) Current status of organ procurement and the proposals for increasing available resources