\n\nThe document discusses numerous historical events related to end-of-life issues from ancient times to modern day. Some key events include the Nuremberg trials establishing an international code of medical ethics in 1949, the development of cardiopulmonary resuscitation in the 1960s, Oregon's Death with Dignity Act legalizing physician-assisted suicide in 1994, and the Supreme Court upholding the Death with Dignity Act in 2006. The document also covers topics like defining death, advance directives, euthanasia, assisted suicide, withdrawal of treatment, and Do Not Resuscitate orders.

2. Chapter 18
End-of-Life Issues
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3. Dreams of Immortality
• Human struggle to survive
• Desire to prevent & cure illness
• Advances in medicine & power to prolong life
• Process of dying can be prolonged
• Ethical & legal issues have increased
– involving entire life span, from right to be born to
right to die
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4. Noteworthy Historical Events - I
• 68,000-58,000 BC: Evidence of Belief
• 1932-72: Tuskegee Study of Syphilis
• 1932-1945: The Holocaust
• 1946: Military Tribunal for War Crimes
• 1949: Nuremberg Trials: Int’l Code of Medical
Ethics
• 1954: First Kidney transplant
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5. Noteworthy Historical Events – II
• 1960s: Cardiopulmonary Resuscitation
• 1964: Guidelines for Research Involving Human
Subjects
• 1968: Harvard Medical School
– Report on Brain Death Criteria
• 1964: World Medical Association
– 1970: Patient as a Person by Paul Ramse
– “paternalism” questioned
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6. Noteworthy Historical Events – III
• 1971: Kennedy Institute of Ethics at Georgetown
• 1972: Informed Consent
• 1973: Women’s Right to Abortion
• 1975: Cloning a Frog
• 1974: National Research Act of 1974
• 1976: Substituted Judgment Permitted
– In the Matter of Karen Ann Quinlan
– First Living Will Legislation
– First Living Will Statute
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7. Noteworthy Historical Events – IV
• 1978: President’s Commission, Study of Ethical
Problems in Medicine
• 1980: Hemlock Society Formed
• 1983: First Durable Power of Attorney
• 1990: Patient Self-Determination Act of 1990
– Feeding tube removed
• 1991: Lethal Dose of Medication Prescribed
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8. Noteworthy Historical Events – V
• 1992: The Final Exit
• 1993: A Patient’s Wishes Honored
• 1994: Death with Dignity Legal Medical Option
– Physician–Assisted Suicide Illegal Act
• 1996: HIPAA
– Constitutional Right to Die
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9. Noteworthy Historical Events – VI
• 1997: Physician-Assisted Suicide Referendum
– Cloning Dolly
– Kevorkian Charged with Murder
– States May Enact Medically Assisted Death Laws
• 1998: Oregon voters reaffirm support for
Death with Dignity Act
– Lethal Injection Televised
– Ballot for Physician-Assisted Suicide Defeated
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10. Noteworthy Historical Events – VII
• 1999: Kevorkian convicted of Murder
• 2000: Seven Myths About End-of-Life Care
• 2001: President's Council on Bioethics Established
– Assisted Suicide Act Challenged
• 2002: U.S. District Court Upholds Oregon’s Death
with Dignity Act
– Attorney General Appeals District Court Decision
• 2003: Human Genome Fully Sequenced
• 2006: Stem Cell Research Controversy
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11. Noteworthy Historical Events – VIII
• 2004: U.S. Circuit Court of Appeals Upholds
Oregon’s Death with Dignity Act
• 2005: “Human Cloning, Ethical Issues” publication
• 2006: US Supreme Court Upholds Death with
Dignity Act
– Blocks Bush’s Attempt to Punish Doctors
– Morning-After-Pill
• 2010: Legislation for Living Will Registry
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12. END-OF-LIFE ISSUES
• Autonomy
– Right of a person to make one’s own decisions.
– Patient has right to accept or refuse care even if it
is beneficial to saving his or her life.
– Autonomy may be inapplicable in certain cases
• affected by one’s disabilities, mental
status, maturity, or incapacity to make
decisions.
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13. Defining Death
• “Irreversible cessation of all brain functions including
the brain stem.”
• Evidence of a patient’s intention to reject the
prolongation of life by artificial means
– Persistence statements regarding individual’s
beliefs
– Desirability of the commitment to those beliefs
– Seriousness with which such statements were
made
– Inferences that may be drawn from surrounding
circumstances 13

14. Constitutional Right to Refuse Care
The Supreme Court analyzed the issues
presented in the Cruzan case in terms of a 14th
Amendment liberty interest, finding that a
competent person has a constitutionally
protected right grounded in the due-process
clause to refuse lifesaving hydration and
nutrition.
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15. Legislative Response
Patient Self-Determination Act of 1990
– enacted to ensure that patients are informed of
their rights to execute advance directives and
accept or refuse medical care
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16. Euthanasia - I
• Mercy killing of hopelessly ill, injured or
incapacitated
• Active Euthanasia
– intentional commission of an act, such as giving
patient lethal drug
• Passive Euthanasia
– occurs when life-saving treatment (such as a
respirator) is withdrawn or withheld
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17. Euthanasia - II
• Voluntary Euthanasia
– occurs when suffering incurable patient makes
decision to die
• Involuntary Euthanasia
– occurs when a person other than incurable makes
decision to terminate life of an incompetent or an
non-consenting competent person's life
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18. Assisted Suicide
• Oregon’s Death with Dignity Act of 1994
• U.S. Supreme Court, in two unanimous & separate
decisions, ruled
– laws in Washington & New York prohibiting
assisted suicide are constitutional
– yet U.S. Supreme Court also ruled that states can
allow doctors to assist in suicide of their terminally
ill patients.
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19. Advance Directives - I
• Instructions given by individuals specifying what
actions should be taken for their health in the event
that they are no longer able to make health care
decisions due to illness or incapacity
– Living Will
• the instrument or legal document that describes those
treatments an individual wishes or does not wish to
receive should he or she become incapacitated and
unable to communicate treatment decisions.
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20. Advance Directives - II
• Health Care Proxy
- Legal document that allows a
person to appoint a health care agent
to make treatment decisions in the
event he or she becomes
incapacitated and is unable to make
decisions for him- or her-self
• Durable Power of Attorney
• Determining Incapacity
• Agent’s Rights
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21. Advance Directives - III
– Durable Power of Attorney
• durable power of attorney is a legal device that
permits one individual, known as the
“principal,” to give to another person, called the
“attorney-in-fact,” the authority to act on his or
her behalf.
– Surrogate Decision-Making
– an agent who acts on behalf of a patient who
lacks the capacity to participate in a particular
decision
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22. Advance Directives - IV
– Substituted Judgment
• form of surrogate decision-making where the
surrogate attempts to establish what decision the
patient would have made if that patient were
competent to do so
– Spousal Rights in Decision-Making
– Guardianship
• legal mechanism by which the court declares a
person incompetent and appoints a guardian
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23. Making Medical Preferences Known
• Patients have an obligation to make medical
preferences known to treating physician.
• Any glimmer of uncertainty as to a patient's
desires in an emergency situation should be
resolved in favor of preserving life.
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24. Futility of Treatment
• Physician recognizes effect of treatment will
be of no benefit to the patient.
• Morally, a physician has a duty to inform
patient when there is little likelihood of
success.
• Determination as to futility of medical care is a
scientific decision.
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25. Withdrawal of Treatment
• Patient is in a terminal condition & there is a
reasonable expectation of imminent death of the
patient
• Patient in a non-cognitive state with no reasonable
possibility of regaining cognitive function
• Restoration of cardiac function will last for a brief
period.
• Feeding Tubes
• When Life-Sustaining Measures Futile
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26. DNR Orders
• DNR orders written by a physician, indicate
that in event of cardiac or respiratory arrest, no
resuscitative measures should be used to
revive patient.
• Competent Patients Make their Own Decisions
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27. Autopsy
• Autopsy consent statutes
• Authorization by the decedent
• Autopsy Consent Statutes
• Authorization by Decedent
• Authorization by other than decedent
• Scope & extent of consent
• Fraudulently obtained consent
• Determination of death
• Unclaimed dead bodies
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28. Organ Donations - I
• Federal regulations require hospitals to have, &
implement, written protocols regarding organization's
organ procurement.
• Regulations impose notification duties concerning
informing families of potential donors.
• Discretion & sensitivity in dealing with families
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29. Organ Donations - II
• Educating hospital staff on variety of issues
involved with donation matters, in order to
facilitate timely donation & transplantation.
• Who Lives? Who Dies? Who Decides?
• Uniform Anatomical Gift Act
• Failure to Obtain Consent
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30. Research, Experimentation & Clinical
Trials
• Institutional Review Board
• Informed Consent
• Research Bill of Rights & Duty to Warn
• Failure to Informed Obtain Consent
• Duty to Warn
• Food & Drug Administration
• Nursing facilities
• Patient Understood the Risks
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31. Human Genetics - I
• Genetic Markers
– DNA sequences with a known location on a
chromosome that can be used to identify specific
cells and diseases, as well as, individuals and
species
• Genetic Information Nondiscrimination Act of
2008
– prohibits discrimination on the basis of genetic
information with respect to the availability of
health insurance and employment
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32. Human Genetics - II
• Stem Cell Research
– use of embryonic stem cells to create organs and various
body tissues
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33. REVIEW QUESTIONS - I
1. What is euthanasia?
2.What is the difference between active and passive
euthanasia?
3. What is the difference between voluntary and
involuntary euthanasia?
4. Describe the different forms of advance directives
(e.g., living will).
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34. REVIEW QUESTIONS - II
5. Discuss the protocol describe in Oregon’s Death with
Dignity Act.
6. Why is organ procurement so important to each
individual?
7. What is a genetic marker?
8. Why was the Genetic Information Nondiscrimination
Act enacted?
9. Discuss why stem cell research so controversial.
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