The Unconscious StatesAwareness of self and the environment.docx

The Unconscious States
Awareness of self and the environment: internal / external
(difficulties)
(lack of response to painful stimulus)
clinical definitions of:
• coma (Glasgow Coma Scale) (induced coma)
• persistent vegetative state (PVS)
• traumatic head injury
• brain hypoxia
• epileptic seizure
• syncope
• other unconscious states (ex. Locked-in syndrome)
CONSCIOUSNESS:
Awareness of self and the environment: internal / external
(difficulties; how to measure?)
UNCONSCIOUSNESS:

Lack of response to painful stimulus
Coma (Glasgow Coma Scale) (induced coma)
persistent (permanent) vegetative state (PVS)
VS MCS
MAGNETIC RESONANCE IMAGING (MRI)
Traumatic Brain Injury (TBI)
• complex injury
• broad spectrum of symptoms
• and disabilities
Mayo Clinic: TraumaticBrainInjury.com
TBI
mild
severe
~ 30 min.
Brain Hypoxia (anoxia)
3 PAIRS OF ARTERIES TO THE HEAD:

• 1 PAIR VERTEBRAL
• 2 PAIRS CAROTID
Epileptic Seizure (epileptic fit)
Neuronal activity:
• Abnormal
• Excessive
• Generalized
• Synchronous
Electro-EncephaloGram (EEG)
Syncope (fainting):
• Temporary loss of consciousness
• Sudden drop in blood pressure
Other unconscious states:
• Non-epileptic seizure
• Locked-in syndrome

• Etc.
LOCKED-IN SYNDROME:
• Aware
• cannot move or communicate verbally
• complete paralysis of nearly all voluntary muscles
• Except for vertical eye movements and blinking
Damage to specific portions of the lower brain
and brainstem, with no damage to the upper
brain (cerebral cortex).
MAGNETIC RESONANCE IMAGING (MRI)
POSITRON EMISSION TOMOGRAPHY (PET)
COMPUTED TOMOGRAPHY (CT)
VEGETATIVE
STATE
MINIMALLY
CONSCIOUS
STATE
LOCKED-IN

SYNDROME
(MRI)
DIAGNOSIS -> PROGNOSIS
MANAGEMENT, RELIEF: PAIN / SUFFERING
BIOETHICAL ANALYSIS: BENEFIT / BURDEN
BIOETHICAL MEANS OF LIFE SUPPORT:
• ORDINARY (PROPORTIONATE) / EXTRAORDINARY
(DISPROPORTIONATE)
CLINICAL MEANS OF LIFE SUPPORT:
• STANDARD MEDICAL PRACTICE / EXPERIMENTAL
TREATMENT
ETHICAL OBLIGATION RE. VITAL ORGANS: ASSIST /
SUBSTITUTE
WHEN TO WITHHOLD OR WITHDRAW LIFE SAVING
TREATMENT?
ERD

32. While every person is obliged to use
ordinary means to preserve his or her health,
no
person should be obliged to submit to a health
care procedure that the person has judged,
with a free and informed conscience, not to
provide a reasonable hope of benefit without
imposing excessive risks and burdens on the
patient or excessive expense to family or
community.
33. The well-being of the whole person must
be taken into account in deciding about any
therapeutic intervention or use of technology.
Therapeutic procedures that are likely to
cause harm or undesirable side-effects can be
justified only by a proportionate benefit to
the patient
56. A person has a moral obligation to use
ordinary or proportionate means of preserving
his or her life. Proportionate means are those
that in the judgment of the patient offer a
reasonable hope of benefit and do not entail
an excessive burden or impose excessive
expense on the family or the community.
57. A person may forgo extraordinary or
disproportionate means of preserving life.
Disproportionate means are those that in the
patient’s judgment do not offer a reasonable
hope of benefit or entail an excessive burden,
or impose excessive expense on the family
or the community.

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LDR/535 v4
LDR/535 v4
Organizational Change Chart
LDR/535 v4
Page 4 of 4
LDR/535 v4
Page 4 of 4
Organizational Information
Select an organization that needed a change to its culture as you
complete the organizational change information chart.
For each type of information listed in the first column, include
details about the organization in the second column.
Indicate your suggested actions for improvement in the third
column.
Type
Details
Suggested Actions for Improvement
Vision
State Farm's ultimate goal is to have its goods and services be
the ones that consumers choose above competitors every time.
Some of the more recent hires lacked familiarity with the
company's long-term goals. Repetition of the vision statement is
important for ingraining it in the minds of personnel.
Mission
State Farm's purpose is to aid its customers in dealing with

life's normal pitfalls, bouncing back from the unexpected, and
realizing their ambitions.
The company's stated objective provides a clear direction for
everyone's efforts.
Purpose
To help others in the community by always being available to
our clients
Everyone who works for the firm is aware of the mission of the
business, which is to give customers the impression that they
can depend on us at all times.
Values
Relationships and services that are of the highest quality;
mutual trust; honesty and reliability; and a solid financial
footing.
The same values and principles that we uphold are the
foundation of our organization's success.
Diversity and Equity
Diversity in every aspect, such as the staff, the market, the
community, and the ties with the many suppliers.
The diversity of State Farm's workforce is a key factor in the
company's success. They are pretty pleased with the culture that
they have developed, which encourages people to behave in a
manner that is authentic to who they are at all times.
Inclusion
Improvements in education, volunteerism, and supplier ties
The employee resource groups (ERGs) serve as a venue in
which employees may network with one another, learn new
skills, and spread knowledge that is not only beneficial to the
company but also to its clients, its community partners, and the
people who live and work in the area.
Goal
The purpose of this project is to revamp our company's
operations so that they better meet the requirements of the
companies that we service and the long-term objectives of the
firm.
Place more emphasis on streamlining departments that have too

many layers of administration and staff.
Strategy
Executive positions, responsibilities, and reporting structures
Because of the sale and leasing of HUB sites, a significant
number of workers have been transferred to other locations, and
the management team has been reorganized in a manner that
isn't really necessary.
Communication
Directors, conferences, electronic mail, and an internal network.
Please alert everyone so that they may know what is
happening.Organizational Perceptions
Considering the same organizational culture and change goal,
rate your agreement from 1 to 5 in the second column with the
statement in the first column. Use the following scale:
1. Strongly disagree
2. Somewhat disagree
3. Neither agree nor disagree
4. Somewhat agree
5. Strongly agree
Statement
Rating (1 – 5)
Employees know the organization’s vision.
5
Employees know the organization’s mission.
4
Employees know the organization’s purpose.
5
Employees know the organization’s values.
5
Overall, the organization is diverse and equitable.
5
Diverse groups are included in decision making and processes
for change.
5
The change goal was successfully met.

4
The implementation strategies were effective.
5
The organization’s communication about the change was
effective.
4
Kotter's 8-Steps to Change
Consider the goal for organizational change that you identified
and the existing organizational culture.
For each of Kotter's 8-Steps to Change listed in the first
column, rate whether you observed that step during the
implementation process in the second column. Use the
following scale to rate your observation:
1. Never observed
2. Rarely observed
3. Sometimes observed
4. Often observed
Identify actions you suggest for improvement in the third
column.
Step Name
Rating (1 – 4)
Suggested Actions for Improvement
Step 1: Create Urgency.
5
Determine what must be altered and justify it to all parties.
Step 2: Form a Powerful Coalition.
5
Put together a group of people with a wide range of
backgrounds from around the company
Step 3: Create a Vision for Change.
5
. Create out the specific plan and put it into action.
Step 4: Communicate the Vision.

4
Appoint a high-ranking manager to spearhead the transition, and
the company as a whole will respond positively.
Step 5: Remove Obstacles.
5
Outline the advantages, drawbacks, and long-term implications.
Step 6: Create Short-Term Wins.
4
Establish a schedule for when each step will be finished, and
commit to the dates you established for the minor changes.
Step 7: Build on the Change.
5
Once the change has taken place, highlight any remaining
opportunities for improvement.
Step 8: Anchor the Changes in Corporate Culture.
5
Make it possible for individuals to share their ideas and take
part in educational activities by providing a forum in which
they may do so.
Copyright 2022 by University of Phoenix. All rights reserved.
image2.png
BIOETHICAL ISSUES TOWARD THE END OF HUMAN LIFE
• TRILLIONS OF CELLS
• VITAL ORGANS

• MAJOR CAUSES OF DEATH
• DISTINCTION BETWEEN ASSISTING OR SUBSTITUTING
VITAL ORGANS
REVIEW:
BIOLOGICAL UNIT OF LIFE = CELL
LEVELS OF BIOLOGICAL ORGANIZATION (HIERARCHY
OF LIFE):
CELLS -> TISSUES -> ORGANS -> SYSTEMS (ORGAN
SYSTEMS) -> ORGANISM
(INDIVIDUAL)
• VITAL ORGANS
VITAL ORGANS:
• BRAIN
• BRAIN STEM
• BOTH LUNGS
• HEART
• LIVER

• PANCREAS
• STOMACH
• SMALL INTESTINE
• LARGE INTESTINE
• BOTH KIDNEYS
• MAJOR CAUSES OF DEATH
% Primary Organ
1. Diseases of the heart 28.5 HEART
2. Malignant tumors 22.8 ANY VITAL ORGAN
3. Cerebrovascular diseases 6.7 BRAIN
4. Chronic lower respiratory diseases 5.1 LUNGS
5. Accidents (unintentional injuries) 4.4 ANY VITAL ORGAN
6. Diabetes mellitus (Type II Diabetes) 3 PANCREAS
7. Influenza and pneumonia 2.7 LUNGS
8. Alzheimer’s disease 2.4 BRAIN
9. Nephritis, nephrotic syndrome and nephrosis 1.7 KIDNEYS

10. Septicemia (blood poisoning) 1.4 BLOOD
11. Suicide 1.3 ANY VITAL ORGAN
12. Chronic liver disease and cirrhosis 1.1 LIVER
13. Primary hypertension and hypertensive renal disease 0.8
ANY VITAL ORGAN
14. Parkinson’s disease (tied) 0.7 BRAIN
15. Homicide (tied) 0.7 ANY VITAL ORGAN
All others 16.7 ANY VITAL ORGAN
100
(Source: CDC/NHS National Vital Statistics System)
15 Major Causes of Death (USA)
VITAL ORGANS
DIALYSIS: SUBSTITUTES KIDNEYS
RESPIRATOR; ASSISTS IN PROVIDING OXYGEN
VENTILATOR; DEPENDS ON THE SETTINGS: ASSIST OR
SUBSTITUTE BREATHING

RESPIRATORS: ASSIST BREATHING
(NOT VENTILATOR)
VENTILATOR: PERFUSION
WEANING PROCESS
VENT ~ 2-3 WEEKS BEFORE TRACHEOTOMY
EXTUBATION
TRACHEOTOMY
(TRACHEOSTOMY)
CARDIOPULMONARY RESUSCITATION (CPR):
• ASSISTS / SUBSTITUTES HEART
Defibrillation
Automated External Defibrillator (AED)
Implantable Cardioverter Defibrillator (ICD)
Wearable Cardioverter Defibrillator (WCD)

• treatment for cardiac dysrhythmias
• Ex. ventricular fibrillation (VF) and ventricular tachycardia
(VT)
• delivers a dose of electric current to the heart
• VITAL ORGANS
VITAL ORGANS
• ASSISTING VITAL ORGANS GENERALLY OBLIGATES
BIOETHICALLY
• SUBSTITUTING VITAL ORGANS GENERALLY DOES NOT
OBLIGATE
Slide Number 1Slide Number 2Slide Number 3Slide Number
12Slide Number 13Slide Number 14Slide Number 15Slide
Number 16
When to Disconnect? Bioethical Distinction between
Assisting or Substituting Vital Organs
Rev. Alfred Cioffi, SThD, PhD
Institute for Bioethics

St. Thomas University
Miami Gardens, Florida
Introduction
Without a doubt, in the United States, life expectancy has been
steadily increasing over
the past half century: in 1950, the average life span for
Americans was about 68.2 years;
in 2015, it was 79.1.i As more people tend to live into old age,
we are experiencing a
larger number of patients on life support systems toward the end
of their life. For
example, a Frontline report of the Public Broadcast System
recently stated that nearly
70% of all Americans die in a hospital, nursing home or long-
term care facility.ii
Often, persons who have a terminal illness or are approaching
the end of their life, and
their loved ones, do not know how much treatment is too much,
and they struggle as to
when to finally stop treatment and allow the patient to die in

peace.iii Conversely,
healthcare professionals during such times may tend to slide
into “extraordinary means”
of life support –bioethically speaking– perhaps simply due to
legal/fiscal concerns
regarding potential lawsuits, or due to the patients’ family
requesting futile care.iv A
general bioethical principle that is very useful in these
situations is the fact that there is
no moral obligation to substitute vital organs. Substituting a
vital organ, in this context,
means totally replacing the vital function of the dying organ,
with either a transplant or
with medical machinery.v This article seeks to explain how this
rule may be applied in
deciding when to stop treatment, and thus allow a patient to die
in peace.
Vital Organs
By definition, a functioning vital organ is essential for
maintaining life. Examples of vital
organs in the human body are: brain, brain stem, heart, both
lungs, liver, whole stomach,

whole intestines, pancreas, both kidneys. It is well known that,
once the death process has
begun, each one of these vital organs has an expected lifespan,
in terms of minutes or
hours, even after the brain and stem have stopped functioning
irreversibly. For example,
without oxygen, within the range of minutes, the lifespan of a
human brain may be less
than four to six minutesvi; for the heart, within twenty
minutes.vii In the range of hours
could be the stomach, intestines, liver and kidneys.viii It is also
well known that each vital
organ of the human body functioning by itself is not sufficient
to maintain life; rather,
each one of these organs must function within its proper organ
system, and all systems
must be integrated –by the nervous system– so as to maintain
human life.
The Death Process
Regardless of how long each vital organ may last after anoxia

(lack of oxygen), when a
vital organ begins to fail irreversibly, one can say that the death
process has begun. One
may never kill an innocent being, but one may allow a person to
die.ix When a moral
dictate is not clear to some, it helps to pose the statement in the
reverse. For example,
imagine if we could not allow people to die; that is an untenable
situation! Therefore,
morally, one may allow people to die. One may have to provide
the means possible for
the dying person to die in peace, but one may certainly allow a
dying person to die.
Hence, whenever a vital organ begins to fail irreversibly, we
can say that the dying
process has begun for that person. Family and friends, and the
healthcare professionals
attending the dying person, in conscience, may allow that
person to die in peace.
Clinically, this may include disconnecting vital support
systems, save those that are
merely assisting the patient (i.e., a respirator, a Foley, or
analgesics).

Assisting versus Substituting
Morally speaking, it is essential to distinguish between assisting
or substituting vital
organs. In other words, assisting vital organs may be considered
standard medical
practice, or the standard of care, including the normal use of
clinical procedures, devices
and/or medications. Bioethically, these are ordinary means of
life support because they
are considered vital or necessary for maintaining life.x
However, when it comes to substituting one or more vital
organs, this typically involves
more elaborate clinical equipment and procedures, including
such sophistications as
general anesthesia and surgery. Typically this becomes
extraordinary means of life
support and, by definition, does not oblige morally.xi
Essentially, the reason why
extraordinary means are not obligatory is because all vital
organs fail naturally sooner or
later; experience inexorably demonstrates that to be so.xii When
this is so, there is no

moral obligation to substitute the dying organ(s) with a healthy
one, or equivalent devices
or machinery.
General Moral Obligation
There is a bioethical obligation to assist vital organs when
possible, but there is no moral
obligation to substitute vital organs when failing irreversibly.
Again, when a moral
dictate is not clear, it helps to pose the statement in the reverse.
For example, imagine if
there was a moral obligation to substitute all vital organs when
failing irreversibly; that
too is untenable! Therefore, there is no moral obligation to
substitute vital organs when
failing irreversibly. One may try to substitute them (i.e.,
transplants), xiii but there is
no moral obligation to do so.

Exception
A possible exception to this bioethical principle is when certain
vital organs are failing in
an otherwise healthy person, and a temporary substitution
presents a positive prognosis.
For example, the otherwise healthy person with pneumonia who,
as a patient, becomes
intubated. One could argue that the ventilator is indeed
substituting the lungs, at least at
first, but the hope is that this intubation be temporary. Another
example could be dialysis,
at least until a matching kidney is found. So, for certain vital
organs and under certain
conditions, one can understand that a temporary substitution of
a failing vital organ may
obligate morally.
Even so, it is also important to further distinguish between short
term and long term
protocols. For example, the intubation of a pneumonia or COPD
patient may be
considered short term (typically, one to two weeksxiv), whereas
dialysis in a patient with

renal failure –considering the current extended waiting lists for
renal transplants– may be
indeed long term (typically, in the range of yearsxv). In such
long term protocols, an
argument could me made that there may come a time when these
procedures no longer
obligate, bioethically speaking. This is also an area where one
finds a possible
discrepancy between standard clinical practice (i.e., dialysis)
and morally extraordinary
means (i.e., substitution of failed kidneys). In such cases,
prudence calls for a patient-by-
patient assessment, including such factors as age, blood type,
genetic makeup, and even
the patient’s own subjective estimation of how burdensome the
procedure is becoming. xvi
Conclusion
Sometimes, patients in healthcare facilities or at home, and their
loved ones, just do not
know when to stop burdensome treatments. If the patient is
terminal but the death process
is not obvious, one can ask the attending physician; “doctor, has
his/her vital organs

begun to shut down irreversibly?” If the answer is, “yes,” then
treatments may be stopped
morally. Bioethically, comfort care always obligates, and this
patient can then be allowed
to die in peace.
i http://www.data360.org/dsg.aspx?Data_Set_Group_Id=195,
accessed 5 June 2016
ii http://www.pbs.org/wgbh/pages/frontline/facing-death/facts-
and-figures/, accessed 5
June 2016
iii Rodriguez KL, Young AJ. Patients' and healthcare providers'
understandings of life-

sustaining treatment: are perceptions of goals shared or
divergent? Soc Sci Med. 2006
Jan;62(1):125-33
ivWillmott L1, et al., Reasons doctors provide futile treatment
at the end of life: a
qualitative study.Med Ethics. 2016 May 17. doi:
10.1136/medethics-2016-103370. [Epub
ahead of print]
v Please note that, for bioethical purposes, the emphasis is on
the function of the vital organ, rather than on
its structure. Thus, a dialysis machine substitutes the kidneys
functionally; conversely, one can say that a
transplanted heart that has been rejected by the patient’s body,
has failed so substitute the dying heart
functionally, even though the structural substitution was
successful.
vi
http://www.nlm.nih.gov/medlineplus/ency/article/000013.htm,
accessed 5 June 2016
vii
http://www.pathology.washington.edu/research/labs/murry/inde
x.php?a=research&p=inf
o, accessed 5 June 2016
viii http://www.dcids.org/facts-about-donation/frequently-
asked-questions/, accessed 5
June 2016

ix Declaration on Euthanasia, Congregation for the Doctrine of
the Faith (1980), Section
IV
x Ethical and Religious Directives for Catholic Health Care
Services (Fifth Ed.), US
Conference of Catholic Bishops (2009), No. 56
xi ERD, 57
xii It is not the scope of this article to delve into why, if all
living cells posses an inherent
reparatory mechanism, do all vital organs end up failing sooner
or later. For inquiry into
this topic, the reader may look up: telomeres and cellular aging.
xiii ERD, 63
xiv http://www.nhlbi.nih.gov/health/health-
topics/topics/vent/whoneeds, accessed 5 June
2016
xv http://www.kidneylink.org/TheWaitingList.aspx, accessed 5
June 2016
xvi ERD, 27
http://www.data360.org/dsg.aspx?Data_Set_Group_Id=195
http://www.pbs.org/wgbh/pages/frontline/facing-death/facts-
and-figures/
http://www.ncbi.nlm.nih.gov/pubmed/?term=Rodriguez%20KL
%5BAuthor%5D&cauthor=true&cauthor_uid=15993530
http://www.ncbi.nlm.nih.gov/pubmed/?term=Young%20AJ%5B
Author%5D&cauthor=true&cauthor_uid=15993530
http://www.ncbi.nlm.nih.gov/pubmed/15993530
http://www.ncbi.nlm.nih.gov/pubmed/?term=Willmott%20L%5B
Author%5D&cauthor=true&cauthor_uid=27188227
http://www.ncbi.nlm.nih.gov/pubmed/27188227

http://www.nlm.nih.gov/medlineplus/ency/article/000013.htm
x.php?a=research&p=info
x.php?a=research&p=info
http://www.dcids.org/facts-about-donation/frequently-asked-
questions/
http://www.nhlbi.nih.gov/health/health-
topics/topics/vent/whoneeds
http://www.kidneylink.org/TheWaitingList.aspx

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