The End Of Life

The End of Life

What is death? What is a good death? How will we all die? “He who has a why to live can bear with almost any how” (Nietzsche) “Everyone knows they’re going to die, but nobody believes it” (Andrew Lustig) “ He passed away “ – termed used for “he died” or to avoid facing the reality of death

What is death?

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b.

Death anxiety – describes fear of the prospect of dying. According to Yalom, individuals avoid facing their own morality in two defenses: Against death is through immorality projects, where people literally throw themselves into commendable projects, their work, or raising children. Though dependence on a rescuer role, believing that another person can provide one with a sense of safety or protection from death

What is death? Strangely enough, it is not being dead; rather, it is the process of dying. Fears of losing control of your body, suffering increasing pain, losing the ability to do things you love to do, being able to make decisions about your medical care, being separated from loved ones: Those are the ways that fears of dying become real. Death is something that pushes the edge of our comprehension (Spiegel)

What is death? Death signifies the end to a person’s living embodiment. Death is a haunting mystery to be discovered rather than a comforting scene with the presence of family members and other hovering over them (Hester) Whatever type of death a person is to experience – a good death; an anticipated death; a sudden unexpected death; or a painful lingering death – most of the time, people do not have a choice to how they will die. Individuals, meanwhile, need to shift the focus from thought “that we die” toward “how we die” so that people can place considerable thought on future decisions about end-of

Euthanasia Mercy killing Good death Easy death Two major types of euthanasia a. Active euthanasia – occurs when persons commit an act to end a life. e.g selfadministered lethal injections of medications ordered by a physician in physician-assisted suicide

Euthanasia Passive euthanasia – when person allows another person to die not taking any action to stop death or prolong life. E.g. withholding some type of treatment that would prevent death Two category of euthanasia a. Voluntary – occurs when patients with decision-making capacity authorize physicians to take their lives.e.g. physician-assisted suicide b.

Euthanasia b.

Nonvoluntary – occurs when persons are not able to do or not express their consent about someone ending their lives. Euthanasia is a morally right and humane act on the grounds of mercy, autonomy and justice (Battin) The principle of mercy is based on two obligations: the duty not to cause further pain and suffering and the duty to act to end existing pain or suffering

Euthanasia The principle of autonomy – is based on the thought that health professional ought to respect a person’s right to choose and determine a suitable course of medical treatment The principle of justice is based on how unsalvageable providers of care believe a permanently unconscious person is; there is moral justification in providers performing euthanasia on patients that they regard as unsalvageable.

Definition of Death

A person who is dead is one who has sustained either a. Irreversible cessation of circulatory and respiratory functions b. Irreversible cessation of all functions of the entire brain, including the brain stem

Four Different Conceptions of Death Traditional – a person is dead when he is no longer breathing and his heart is not beating Whole – brain – death is regarded as the irreversible cessation of all brain functions… no electrical activity in the brain, and even the brain stem is not functioning

Four Different Conceptions of Death Higher-brain – death is considered to involve the permanent loss of consciousness.. Someone in an irreversible coma would be considered dead, even though the brain stem continued to regulate breathing and heartbeat Personhood – death occurs when an individual ceases to be a person. This may mean loss of features that are essential to personal identity or for being a person

Criteria to establish whole-brain death Flat EEG with other tests that document the absence of cerebral blood flow Fixed and dilated pupils Inability to breath without mechanical support Absent brain stem reflexes

Advance Directive Is a written expression of a person’s wishes about medical care especially care during a terminal or critical illness

Living will Are written documents that direct treatment in accordance with a client’s wishes in the event of terminal illness or condition Each state has a requirement for the living will Problems arise in living will – vague language, contain only instructions for unwanted treatments, lack a description of legal penalties for those people who choose to ignore the directives of living will, and when living will are legally questionable as to their authenticity

Medical Care Directive Is not a formal legal document but provides specific written instructions to the physician concerning the type of care and treatments that individuals want to receive if they become incapacitated Advantage: physician use them as guide to know what incapacitated patients want in terms of specific health care treatments

Medical Care Directive Disadvantage: people cannot possible anticipate every medical problem that may occur in their future.

Durable power of attorney Is a legal written directive in which a designated person is allowed to make either general or specific health care and medical decisions for a patient Has the most strength for facilitating health care decision There should be a durable power of attorney for health care decisions on his or her own behalf

Deciding for Other When patients can no longer make competent decisions, families may experience problems in trying to determine a progressive right course of action The ideal situation is for patients to be autonomous decision makers but, when autonomy is no longer possible, decision making falls to a surrogate Surrogate/proxy – either chosen by the patient, is court appointed, or has authority to make decisions

Deciding for Other Before any decision are made by a proxy, there needs to be appropriate dialogue among the physician, nurses, and the proxy. Surrogate or proxy is either chosen by the patient, is court appointed, or has other authority to make decision Proxies may not be able to distinguish between their own emotions and concerns for patients or they may have monetary motives for making certain decisions

Deciding for Other It is the responsibility of nurses and physicians to be observant for these kinds of motives or concerns and then to look for therapeutic ways to deliberate with the proxy Three types of surrogate decision making: a. Standard of substituted judgment – is used to guide medical decisions that involve formerly competent patients who no longer have any decision-making capacity

Deciding for Other b. Pure autonomy standard – based on a

decision that was made by an autonomous patient while competent but later drifts to incompetency c. Standard of best interest – based on the goal of the surrogate’s doing what is best for the patient or what is in the best interest of the patient

Medical Futility Futile – represents pointless or meaningless events or objects When a health care provider cannot have reasonable hope that a treatment will be of benefit for a terminally ill person, the medical treatment is considered to be futile care.  Cardiopulmonary resuscitation (CPR)  Medications

Medical Futility  Mechanical ventilation  Artificial feeding and fluids  Hemodialysis  Chemotherapy  Other life-sustaining technologies

Right to Die and Right to Refuse Treatment Well-informed patients with decision-making capacity have an autonomous right to refuse and forego recommended treatments Most of the time there are no ethical or legal ramifications if a person decides to forego treatment The courts uphold the right of competent patients to refuse treatment Health care professionals need to make certain that the patient’s decision is truly autonomous and not coerced

Right to Die and Right to Refuse Treatment Health care professionals may find it very difficult to accept a competent patient’s decision to forego treatment

Withholding and withdrawing LifeSustaining Treatment Nurses need to give compassionate and excellent care to patients. No matter what decision is made, family members and patients need to feel a sense of confidence that nurse will maintain moral sensitivity with a course of right action Nurses ethically support the provision of compassionate and dignified end-of-life care as long as nurses do not have the sole intention of ending a person’s life

Alleviation of Pain and Suffering in the Dying Patient Attempting to relieve pain and suffering is a primary responsibility for nurse and providers of care. Patients fear the consequences of disease, that is, they fear pain, suffering, and the process of dying

Rule of Double Effect It is defined as the use of high doses of pain medication to reduce the chronic and intractable pain of terminally ill patients even if doing so hastens death Nurses may have conflicting moral values concerning the use of high doses of opioids, such as morphine sulfate and other medications. In times when nurses feel uncomfortable, they need to explore their attitude and opinions with their supervisor and when appropriate, in clinical team meetings.

Terminal Sedation Is a phrase that did not appear in the literature until the 1990s No clear consensus regarding its meaning “When suffering patient is sedated to unconsciousness, usually through the ongoing administration of barbiturates or benzodiazepines. The patient then dies of dehydration, starvation or some other intervening complication, as all other lifesustaining interventions are withheld.” (Quill)

Terminal Sedation TS has been used in three situations: a. To provide relief of physical pain b. To produce unconsciousness before withdrawing artificial food and fluids c. To relieve suffering Nurses are not to have the sole intent of ending a person’s life. Nurses need to evaluate the intentions of physicians’ orders to the extent possible and the intentions of their own actions when giving care to patients in questionable TS situation.

Physician-Assisted Suicide The act of providing a lethal dose of medication for the patient to self-administer Special guidelines relating to the Death With Dignity Act in Oregon were written by the ONA for nurses who care for patients who choose physician assisted suicide. The guidelines includes maintaining support, comfort and confidentiality; discussing end-of-life options with the patient and family and being present for the patient’s self-administration of medications and during the death.

Physician-Assisted Suicide Nurses may not inject the medications themselves, breach confidentiality, subject others to any type of judgmental comments or statements about the patient, or refuse to provide care to the patient.

Rational Suicide Is a self-slaying based on reasoned choice and is categorized as voluntary active euthanasia Siegel stated that the person who is contemplating rational suicide 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

Rational Suicide For nurse to endorse any suicide seems contradictory to good practice, because traditionally nurses and mental health professionals have intervened to prevent suicide

Rational Suicide According to Rich and Butts there are no clear answers to this ethical dilemma but interventions become unique to each situation. Interventions may include everything from being asked to provide information regarding the Hemlock Society to being asked about lethal injections. Autonomy and beneficence need to be considered when nurses are deciding on interventions for persons who are planning rational suicide.

Moral problems encountered by nurses: Communicating truthfully with patients about death because they were fearful of destroying all hope in the patient and family Managing pain symptoms because of fear of hastening death Feeling forced to collaborate with other health team members about medical treatments that in the nurses’ opinion are futile or too burdensome

Moral problems encountered by nurses: Feeling insecure and not adequately informed about reasons for treatment Trying to maintain their own moral integrity throughout relationships with patients, families, and co-workers because of feeling that they are forced to betray their won moral values

Management of Care

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The compassionate Nurse with a dying patient Physical and emotional pain management Core principles for end-of-life care Because death is an essential human passage, nurses must acknowledge and respect the passage. Nurses, significant others and patients themselves have an impact on how that passage occurs Always consider whether or not patients actually desire an optimal level of pain management and sedation to relieve pain and suffering and respect their wishes. Patients may wish for a balance between alertness and level of comfort so that they can chat and feel the presence of others

3. Palliative care should be comprehensive and

flexible for pain and symptoms management. Treatments are warranted to enhance quality of life 4. Avoid offering treatment options or any other options that are unrealistic. Dying patients are very limited as to their choices and options and do not need to be offered treatment options that do not have any beneficial effects

5. Be respectful of the time that patients

and family members need for coming to terms with their loved one’s death, and for their own spiritual practices 6. Be respectful of time that is needed for family members or significant others to grieve, to come to terms with their loved one’s death, and for their own spiritual practices

7. Give attentive end-of-life care to dying

patients so that the ones who are grieving can witness the nurse’s impact on the facilitation of human passage. The sight of well-cared-for dying loved ones promotes emotional and physical well-being among the grieving family members and significant others 8. Avoid universal precautions and expectations for dying patients. Every death and death narrative is unique

“There is such an absoluteness to death. Harsh words cannot be taken back. Promises is unfulfilled can never be completed. One cannot even say goodbye. Facing the absoluteness of death can be a tremendous stimulus to life. If it is important, do it now… Say what you mean to say. Settle old grievances. Accomplish what needs doing, sooner rather than later… Death is so overwhelming that it is rather humbling. There seems to be so little one can do

about it . Strangely enough, we always resort to the same comfort: our sense of caring about one another. In some sense, we huddle together. Our bond of caring forms a kind of talisman against the power of death. Although, ultimately, each of us has to face death alone, it is a tremendous relief to do some of the work with someone else. A good hug or some shared tears may not save a life, but it will make you feel more alive (Spiegel)

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Spiritual considerations Spirituality is one of the most important aspects of endof-life nursing care, but often nurses feel helpless when it comes to providing the right type of spiritual care for their patients Spirituality is the one of the essential to nursing care which is included in the palliative care According to Dossey and Guzzetta, spirituality is a unifying force of a person; the essence of being that permeates all of life and is manifested in one’s being, knowing, and doing the interconnectedness with self, others, nature and God/Life/Force/Absolute/Transcedent

1. 2. 3. 4. 5. 6.

Six categories and specific nursing interventions for spirituality care: Kindness and respect Talking and listening Prayer Connecting Quality temporal nursing care Mobilizing religious or spiritual resources

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There are no completely “right” ways to help a person die because of individualized dying processes The involvement of nurses in decisions about death becomes more complex everyday as more technology is incorporated into the dying process. Family members and patients must be involved with all ethical decisions that are made